TrWBIWHI W NH i IBB 



in 

vSSSSSa 


WSB& 


88 


iSoS 


SB 


k] tdo« HHHHMQt 


38? 


KSflflflffi 




£9 



■BflfifiHffl ffi 









■nra 



■sSaSSSSSBs 




took -J_^_ 

COPYRIGHT DEPOSIT 



&■■&$:£&£: 



■ Hi m 



■ 

H §§£1 




SSsKlSSJiJwri 






■ 




'V^jfe 


KBg 




^^| 




«HKq 




MJgHra 




si 113 




If&slp 




llil 




nnn h 



A MANUAL 

OF 

AUSCULTATION AND PEKCUSSION 

EMBRACING THE 

PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS 

AND HEART AND OF THORACIC ANEURYSM 

AND OF OTHER PARTS 

BY 

AUSTIN FLINT, M.D., LL.D. 

LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL 
MEDICINE IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC. 

SIXTH EDITION, REVISED AND ENLARGED BY 
HAVEN EMERSON, A.M., M.D. 

ASSOCIATE IN PHYSIOLOGY AND ASSOCIATE IN MEDICINE, COLLEGE OF PHYSICIANS 

AND SURGEONS OF -COLUMBIA UNIVERSITY; ASSISTANT VISITING 

PHYSICIAN, BELLEVUE HOSPITAL 

ILLUSTRATED 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1912 



« 



. '^ 



Entered according to the Act of Congress, in the year 1912, by 
LEA & FEBIGER, 

in the Office of the Librarian of Congress. All rights reserved. 



SCI.A320662 



PREFACE TO SIXTH EDITION 



By permission of the son of the late author, the 
editor is privileged to present this invaluable "Manual " 
again to the medical student and practitioner. 

It is fitting that the final form of a work which went 
through four editions under the direct revising hand 
of one of the masters of the science of physical diag- 
nosis should be retained. The principles, the method, 
the limitations, the practical conclusions of physical 
examination of the thoracic viscera have never been 
more clearly nor more effectively described in English. 
The field of theory, -the countless variations in method, 
the rarities of pathological and clinical experience must 
still be studied in the great works on diagnosis, to which 
we must turn for exhaustive discussions. The par- 
ticular need which this book was intended to fill, and 
which it is expected that it will again fill, is the demand 
of the student and of many a graduate in medicine 
for simplicity, directness, exactness, and authority, in 
dealing with physical signs in health and disease. 

The need of examination of the abdominal viscera 
and of the nervous system, carried out as carefully as 
the usual examination of the heart and lungs, excuses 
the addition of the two chapters dealing with these 
subjects. 



IV PREFACE 

The advantage to be gained in difficult cases, and 
the accuracy and confirmation to be had in all cases, 
by the use of various accessory mechanical methods 
of examination, justifies reference to the principles and 
methods of these procedures. 

For encouragement and assistance in the prepa- 
ration of this edition the editor is indebted to Dr. 
Theodore C. Jane way. 

Haven Emerson. 

New York, 1912. 



INTRODUCTORY 



It was with much satisfaction that I gave my 
hearty approval to the republication, with additions, 
of Flint's Manual of Auscultation and Percussion. 
This I regard as a fitting tribute to the memory of 
its distinguished author, as it extends to present and 
future students of medicine the benefits of the teach- 
ings he so loved to impart. 

The letter-press has been retained with but slight 
alteration, for the book was a masterpiece of clarity 
and precision. Few medical writers have been gifted 
with the elegance of diction illustrated in this little 
work. 

The additions by the editor to the original chapters 
embrace certain new and valuable methods of ex- 
amination that have arisen within the last twenty-five 
years. 

In the interest of completeness new chapters have 
been added, giving methods of physical examination 
of the abdominal viscera, and of the nervous system. 

Austin Flint. 
New York, 1912. 



CONTENTS 



CHAPTER I 



Introduction. Anatomical, Physiological, Patho- 
logical, and Physical Principles Involved in 
Percussion and Auscultation of the Chest . 17 

CHAPTER II 
Percussion in Health 51 

CHAPTER III 
Percussion in Disease 73 

CHAPTER IV 
Auscultation in Health 86 

CHAPTER V 

Auscultation in Disease 109 

CHAPTER VI 

The Physical Diagnosis of Diseases of the Respi- 
ratory System 168 

CHAPTER VII 

The Physical Conditions of the Heart in Health 
and Disease, the Heart Sounds and Cardiac 
Murmurs 222 



Vlll CONTENTS 

CHAPTER VIII 

The Physical Diagnosis of Diseases of the Heart 

and of Thoracic Aneurism . . . . .281 

CHAPTER IX 

The Physical Examination of the Abdominal 

Viscera . • 311 

CHAPTER X 
The Physical Examination of the Nervous System . 321 

CHAPTER XI 

Accessory Methods and Order of Physical Examina- 
tion 343 



AUSCULTATION AND PERCUSSION 



CHAPTER I 
INTRODUCTION 

Definition of percussion and auscultation — The sounds 
obtained by these methods of representing healthy and morbid 
physical conditions— Definition of signs — The basis of our 
knowledge of signs the constancy of association of certain sounds 
with certain physical conditions in health and disease — The 
present state of perfection of our knowledge of signs furnished 
by auscultation and percussion — Requirements for the success- 
ful study of these methods of exploration — The anatomy and 
physiology of the chest — An enumeration of the points relating 
thereto which are of special importance — The physical condition 
incident to the different diseases of the chest: the conditions 
relating to the respiratory system stated, and a summary of 
them — The distinctive characters of healthy and morbid signs; 
variations in intensity, pitch, and quality, considered as the 
chief source of the character distinguishing the signs of disease 
from each other and from those of health — Other distinctions 
than those of intensity, pitch, and quality — The analytical 
method of the study of auscultation and percussion — The 
signifiance of signs as regards the physical conditions which they 
severally represent — Morbid conditions, not individual diseases 
represented by the morbid signs — Regional divisions of the 
chest — Anatomical relations of the regions severally to the parts 
within the chest. 

PHYSICAL EXPLORATION 

The physical examination of the chest embraces 
six different methods — namely, inspection, palpation, 

2 



18 INTRODUCTION 

mensuration, percussion, auscultation, and succussion. 
Of these, percussion, auscultation, and succussion 
dealing with sounds involve the sense of hearing. In 
percussion the sounds are produced by striking upon 
the walls of the chest; in auscultation, they are caused 
by acts of breathing, speaking, and coughing, in suc- 
cussion they are caused by splashing of fluids when 
the body is shoved abruptly, or shaken. 

The sounds in auscultation and percussion are (1) 
normal or healthy sounds, being produced when there 
is no disease of the chest; and (2) abnormal or morbid 
sounds, being produced when the chest is the seat of 
disease. The sounds, healthy and morbid, constitute 
what are known as physical signs. Frequently, for 
the sake of brevity, the term signs, without the word 
physical, is used to denote these sounds. Conven- 
tionally, physical signs, or signs, are terms employed 
in a sense of contradistinction to the term symptoms. 
The signs are distinguished, of course, as normal or 
healthy, and abnormal or morbid. 

The sounds which constitute signs represent certain 
physical conditions pertaining to the chest. The 
normal or healthy signs represent physical conditions 
existing when the organs are not affected by disease; 
the abnormal or morbid signs represent physical 
conditions which are deviations from those of health, 
being incident to the various diseases of the chest. 
The physical conditions represented by signs may be 
distinguished as normal or healthy, and abnormal 
or morbid conditions. 

The representation of healthy and morbid physical 



PHYSICAL EXPLORATION 19 

conditions by certain healthy and morbid signs is 
established by having ascertained a constancy of 
association of the signs with the conditions. This 
constancy of association is ascertained by observation 
or experience. The sounds obtained by percussion 
and auscultation in health are thereby established 
signs of healthy conditions, and the sounds obtained 
only in cases of disease are thereby established signs 
of morbid conditions. Our knowledge of certain 
sounds as the signs of certain physical conditions can 
have no reliable basis other than the constancy of 
the connection of the former with the latter. This 
constancy of connection is determined by the study 
of the sounds during life and examination of the 
organs after death. The existence of certain conditions 
is not to be inferred from the characters of certain 
sounds until the connection of the sounds with the 
conditions has been ascertained by experience; then, 
and then only, are the sounds to be reckoned as signs 
of these conditions. So, also, it is not to be inferred 
from certain physical conditions found after death, 
that certain sounds must have been produced during 
life, until the connection between the conditions and 
the sounds has been ascertained by experience. In 
other words, our knowledge of signs as representing 
physical conditions, can rest on no other than a purely 
empirical foundation. 

Our knowledge of the signs representing the phy- 
sical conditions in health and disease, thanks to the 
labors of Laennec, and of those who have followed 
in his footsteps, has been brought to great perfec- 



20 INTRODUCTION 

tion. 1 The practical object of this knowledge is to 
determine by means of auscultation and percussion, 
together with the other methods of exploration, the 
existence of either healthy or morbid physical condi- 
tions, and to discriminate the latter from each other; 
that is to say, the practical object is diagnosis. The 
signs now known to represent physical conditions, 
healthy and morbid, taken in connection with symp- 
toms and pathological laws, render, for the most part, 
the diagnosis of diseases of the chest easy and posi- 
tive. Hence, it becomes the duty of the medical 
student and practitioner to give to auscultation and 
percussion attention sufficient, at least, for their 
practical application to the diagnosis of the diseases 
commonly met with in medical practice; and this duty 
is the more imperative because it involves neither 
peculiar difficulties nor great labor. In entering 
upon the undertaking it is important to consider the 
requirements for the successful study of this province 
of practical medicine. These requirements relate to: 
(1) the anatomy and physiology of the chest; (2) the 
morbid physical conditions incident to the different 
diseases of the chest; (3) the distinctive character of 
healthy and morbid signs; and (4) the signifiance 
of the signs as regards the physical conditions which 
they severally represent. 

1 We owe a debt also to Auenbrugger, who preceded Laennec, 
and to Wintrich, Skoda, Traube, and Gerhardt particularly 
among his successors. 



ANATOMY OF THE RESPIRATORY ORGANS 21 

ANATOMY AND PHYSIOLOGY OF THE RESPIRA- 
TORY ORGANS 

The necessity of a knowledge of the antomy and 
physiology of the chest, as a requirement for the 
study of auscultation and percussion, together with 
the other methods of physical exploration, is too 
obvious to need any discussion. The physical con- 
ditions of health must be known as preparatory for 
appreciating the physical conditions of disease. It 
would be absurd to think of studying the latter until 
the former are known. The student, therefore, who 
is not acquainted with the anatomy and physiology 
of the chest, must defer entering upon the study of 
physical diagnosis until this requirement is fulfilled. 
Familiarity with the morbid physical conditions is 
necessary; and for the advanced medical student or 
the practitioner it is advisable to refresh the memory 
with a reviewal of certain anatomical and physiological 
points before beginning the study of auscultation and 
percussion. These points, relating especially to the 
physical conditions of health, cannot be considered in 
this work. A simple enumeration of them only can be 
introduced, the reader being referred for details to 
treatises on anatomy and physiology. 

Important anatomical conditions relate to the 
bones of the chest — namely, the general conforma- 
tion of the thorax, the differences in respect of the 
obliquity of the ribs from above downward; the direc- 
tion of the costal cartilages, their connection with 
the sternum, and the angles formed by the junction 



22 INTRODUCTION 

of the ribs and cartilages; the differences in width 
of the intercostal spaces in the upper, middle, and 
lower portions of the anterior, lateral, and posterior 
aspects of the thorax, together with the relations of 
the scapula and clavicle. The relative thickness 
of the muscular covering of the chest in different 
situations is to be considered, and, in women, the 
varying size of the mammae. The attachments of 
the diaphragm to the thoracic walls, and its relations 
to the organs below, as well as above it, are points of 
importance (Figs. 1, 2, 3, 4). 

Important physiological conditions relate to the 
parts which the ribs, costal cartilages, sternum, and 
diaphragm severally play in the movements of respi- 
ration. The differences, in respect of these move- 
ments, in tranquil and in forced breathing, the 
contrast between the two sexes, and between early 
and advanced life, are points to be studied. Other 
points are, the frequency of the respirations in health, 
and the relative duration, rapidity, and force of the 
inspiratory and the expiratory movements. 

Certain anatomical and physiological points per- 
tain to the organs within the chest. The more impor- 
tant of these, relating to normal physical conditions, 
are the following: (1) As regards the lungs, the con- 
nections of the pleura, and the smoothness of the 
pleural surfaces in contact with each other; the relations 
of the apex and base of each lung to the chest-walls, 
and the differences of the two lungs in this respect; 
the relative spaces occupied respectively by the two 
lobes of the left, and the three lobes of the right lung; 



PHYSIOLOGY OF THE RESPIRATORY ORGANS 23 

the situation of the interlobar fissures in either side 
on the posterior, lateral, and anterior aspects of the 
chest; the arrangement of the air- vesicles, pulmonary 
lobules, and the different-sized intra-pulmonary bron- 
chial tubes; the expansion of the air- vesicles, and the 
movement of the current of air from larger to smaller 
bronchial tubes in the act of inspiration, the vesicles 
diminishing in size, and the current of air moving 
from smaller to larger tubes in the act of expiration; 
the difference in respect to the relative proportion 
of air and solids at the end of inspiration and at the 
end of expiration; the extent to which the volume 
of the lungs may be diminished by a forced act of 
expiration, and increased by a forced act of inspira- 
tion; the relations of the apices to the subclavian 
arteries, and the variable extent to which the apex 
rises on either side above the clavicle. (2) As regards 
the larynx, trachea, and the bronchial tubes with- 
out the lungs; the anatomy and physiology of the 
vocal chords ; of the muscles concerned in the move- 
ments of respiration and of phonation, with the rela- 
tions of each to the recurrent laryngeal nerve; the 
size of the rima glottidis in youth, after puberty, 
and relatively in the two sexes; the enlargement of 
the rima in the act of inspiration, the diminution of its 
size in the act of expiration, and the closer approxi- 
mation of the chords in the act of coughing; the 
difference in the amount of areolar tissue above the 
vocal chords in children and in adults; the situation 
of the trachea and the point of its bifurcation; the 
length, direction, and size of the two primary bronchi 



24 INTRODUCTION 

contrasted with each other, and the branches which 
penetrate the lungs. (3) As regards the heart, the 
boundaries of the space which it occupies — that is, 
of the precordial space; the relation of the aorta and 
pulmonic artery to the walls of the chest; the portions 
of the precordial space in which the heart is covered 
and uncovered by lung; the situations of the auricles 
and ventricles respectively; the relations of these to 
each other, and the arrangements of the valves; the 
currents of blood through the orifices within the 
heart, and the relations of each of these to the heart- 
sounds; the rhythmical succession of these sounds; 
the differences which distinguish each from the other 
in respect of loudness, duration, tone, quality, extent 
of diffusion, and the situation in which each has its 
maximun of intensity; the mechanism of these sounds, 
and the situation of the apex-beat (Figs. 1, 2, 3, 4). 

The foregoing are the anatomical and physio- 
logical points which especially claim attention with 
reference to normal physical conditions, preparatory 
to entering on the study of abnormal physical con- 
ditions represented by the signs furnished by auscul- 
tation and percussion together with the other methods 
of physical exploration. 

It is recommended to the student, before proceed- 
ing farther, either to acquire or review knowledge 
respecting all these points. Knowledge of these 
should be made familiar, if it be not already so, 
by reference to works treating of the anatomy and 
physiology of the chest. 



DISEASES OF THE RESPIRATORY SYSTEM 25 



THE MORBID PHYSICAL CONDITIONS INCIDENT 

TO THE DIFFERENT DISEASES OF THE 

RESPIRATORY SYSTEM 

The various morbid physical conditions incident 
to different diseases must be known, for it is the 
immediate object of auscultation, percussion, and the 
other methods of exploration, to ascertain either 
the existence or the absence of these morbid con- 
ditions. Knowledge of all the important conditions 
which are deviations from those of health, and the 
relations of each to different diseases, is, therefore, 
an essential requirement. 

Deviations from the normal conformation of the 
chest and the various abnormal movements of respi- 
ration, belong properly among the physical signs 
obtained by inspection, palpation, and mensuration. 
For the most part, these signs represent morbid 
physical conditions within the chest. Certain con- 
ditions relate to the presence of liquid, either serous, 
sero-fibrinous, or purulent, within the pleural sac. The 
quantity of liquid may be large enough to compress 
the lung into a solid mass, and to enlarge the affected 
side, at the same time restraining or annulling the 
respiratory movements; the chest on the affected 
side, then, will contain only lung solidified by com- 
pression, and liquid. In other cases the quantity of 
liquid is either small, moderate, or considerable, the 
lung then containing a lessened quantity of air, and 
its volume diminished in proportion to the amount 



26 INTRODUCTION 

of liquid. These morbid conditions are incident to 
simple pleurisy with effusion, pyothorax or empyema, 
and hydrothorax. 

The pleural surfaces, in cases of pleurisy, may be 
more or less covered with recent fibrinous exudation, 
and, when not separated by the presence of liquid, 
they do not move upon each other smoothly and 
noiselessly. The friction of the opposed surfaces 
is still more productive of audible and sometimes 
tactile signs after the absorption of liquid, when the 
exudation has become more adherent and dense than 
when it is recent. 

The presence of air in the pleural space, either 
alone or with more or less liquid, in pneumothorax, 
may compress the lung into a solid mass, also dilat- 
ing the affected side, and restraining or annulling its 
movements; and the air, with or without liquid, when 
not in sufficient quantity to produce these effects, 
may diminish more or less the volume of the lung 
and the amount of air in the pulmonary vesicles. 
These morbid conditions give rise to characteristic 
physical signs. The perforation of lung, usually exist- 
ing in cases of pneumothorax, occasions additional 
signs which are characteristic. 

Solidification of lung is an important physical 
condition incident to several diseases, irrespective 
of the condensation, just referred to, caused by the 
compression of liquid or air in the pleural sac. Com- 
plete consolidation of an entire lobe, or of two and 
even three lobes, exists in the second stage of lobar 
pneumonia. Certain physical signs represent this 



DISEASES OF THE RESPIRATORY SYSTEM 27 

condition of complete solidification. 1 The different 
degrees of solidification, namely, slight, moderate, and 
considerable, occur during the stage of resolution in 
cases of pneumonia, and these gradations are severally 
represented by well-defined characters pertaining to 
physical signs. Solidification, circumscribed, forming 
nodules which vary in size and number, situated 
in the upper, lower, or middle portion of the lung, 
either on one side or on both sides, exists in phthisis, 
in broncho-pneumonia and collapse of pulmonary 
lobules, in hydatids, in hemorrhagic infarctus and 
embolic pneumonia, in pulmonary gangrene, and in 
primary and secondary neoplastic growths. It exists, 
greater or less in degree and more or less extended, 
in interstitial pneumonia. In these different con- 
nections the existence of solidification, its degree and 
extent, its limitation to one situation or its existence 
at different points, are determinable by means of 
physical signs. 

A morbid condition the opposite of solidification 
is an abnormal accumulation of air within the air- 
vesicles of the lungs. This is incident to pulmonary 
or vesicular emphysema, involving a morbid dilata- 
tion of the air-vesicles. The permanent expansion 
and increased volume of the upper lobes in some 

1 The term complete consolidation as used here is not 
intended to indicate a filling of the large subdivisions of the 
bronchi with exudate in the affected lobe. This extreme 
condition may occur and is described as massive consolidation. 
In this form certain of the physical signs are markedly 
altered, the breath and voice sounds being diminished or entirely 
suppressed. 



28 INTRODUCTION 

cases of this disease, occasion a characteristic de- 
formity of the chest, together with certain devia- 
tions from the normal movements of respiration, 
which are also characteristic. This morbid condi- 
tion is represented by distinctive signs furnished by 
auscultation and percussion. The extravasation of 
air in the connective tissue, constituting interlobular 
and subpleural emphysema, in like manner gives rise 
to signs furnished by these methods of exploration. 

The presence of a viscid exudation within the 
air-vesicles and bronchioles, is a morbid physical con- 
dition incident to acute pneumonia, especially in its 
first stage, agglutinating the cells and bronchioles, 
the walls of which may be brought into contact or 
close proximity at the end of the act of expiration. 
The separation of the walls thus agglutinated, in 
the act of inspiration, gives rise to an auscultatory 
sign (the crepitant rale). 

An accumulation of serum within the air-vesicles 
constitutes the condition called pulmonary edema. 
This condition gives rise to signs furnished by aus- 
cultation and percussion. 

Liquid within the bronchial tubes (serum, pus, 
blood, or thin mucus) is a condition incident to pul- 
monary edema, abscess either of the lung or situated 
elsewhere and evacuating through the bronchial 
tubes, phthisis, bronchorrhagia, pneumorrhagia, bron- 
chorrhea, and bronchitis. The passage of air through 
the different varieties of liquid in the tubes causes 
bubbling sounds which are appreciable in ausculta- 
tion. The apparent size of the bubbles (coarseness or 



DISEASES OF THE RESPIRATORY SYSTEM 29 

fineness) denotes the size of the tubes in which they are 
produced, and the pitch of the bubbling sounds denotes 
either solidification or otherwise of the pulmonary 
substance surrounding the tubes in which the bubbles 
are produced. Bubbling sounds more intense and on 
a larger scale are caused by the presence of liquid 
within the trachea and larynx, known as the tracheal 
rales or the death rattle. 

Diminished calibre of the bronchial tubes within 
the lungs, either localized or diffused, is a condition 
due to the presence of tenacious mucus, and the swell- 
ing of the mucous membrane in cases of bronchitis. 
In cases of so-called capillary bronchitis the condition 
may involve an alarming degree of obstruction. The 
same morbid condition is incident to bronchial spasm 
in asthma, occasioning in this disease great suffering, 
but without immediate danger. The condition is 
represented by auscultatory signs which enable the 
auscultator to differentiate the obstruction due to 
capillary bronchitis from that due to bronchial spasm. 
Permanent obliteration of more or less of the bronchial 
tubes is an occasional morbid condition. 

Obstruction of a bronchial tube, either within or 
without the lung, is a morbid condition involving 
the loss of respiratory sound within the area of the 
bronchial branches and vesicles not receiving air in 
consequence of the obstruction. The obstruction 
may be temporary, being caused by a plug of mucus 
of sufficient size to prevent the passage of air; the 
morbid condition is then incident to bronchitis. One 
of the primary bronchi may be obstructed temporarily 



30 INTRODUCTION 

by a plug of mucus, and obstruction of the larynx 
in childhood thus produced may be sufficient to cause 
death by suffocation. The inhalation of foreign 
bodies is another cause of obstruction within the 
larynx, trachea, or bronchi. A primary bronchus or 
the trachea may be pressed upon by an aneurismal 
or other tumor, and, in this way, more or less obstruc- 
tion to the passage of air is produced. However 
produced, the situation of the obstruction and its 
degree are, in general, determinable by means of 
auscultatory signs. 

Dilatation of bronchial tubes occasions two morbid 
physical conditions differing as regards their auscul- 
tatory signs — namely, (1) an enlargement of greater 
or less extent, the tubes preserving their cylindrical 
form; and (2) a sacculated enlargement. The former 
occurs generally in connection with solidification 
around the tubes from hyperplasia of the areolar 
tissue, and is thus incident to interstitial pneumonia. 
The latter may give rise to signs which represent 
pulmonary cavities. 

Sacculated dilatations of bronchial tubes, and the 
cavities incident to phthisis, pulmonary abscess and 
circumscribed gangrene of lung, are represented by 
well-marked and highly distinctive signs furnished 
by auscultation and percussion. The signs denote 
either that cavities have flaccid walls which collapse 
in expiration and expand in inspiration, or that, owing 
to solidification of lung, they remain open during 
both acts of respiration. 

More or less of the space within the chest which, 



DISEASES OF THE RESPIRATORY ORGANS 31 

normally, is occupied by lung, may be encroached 
upon by aneurisms or other intra-thoracic tumors. 
This is a physical condition giving rise to notable 
morbid signs furnished by auscultation and percussion. 

Finally, an extremely rare morbid physical con- 
dition is the presence of more or less of the hollow 
viscera of the abdomen within the chest, in con- 
sequence of either a congenital deficiency in the 
diaphragm, or a wound penetrating this muscle 
(diaphragmatic hernia). 

The foregoing morbid physical conditions relate 
to the respiratory organs. Those relating to the 
heart are deferred in order that they may precede 
more immediately an account of the signs of cardiac 
disease. As a requirement for the study of morbid 
physical signs, the foregoing morbid physical con- 
ditions must be understood and memorized. To 
assist the student in the latter, a summary of these 
conditions is appended. 

SUMMARY OF MORBID PHYSICAL CONDITIONS 

INCIDENT TO DISEASES OF THE 

RESPIRATORY ORGANS 

1. An accumulation of serous, sero-fibrinous, or 
purulent liquid sufficient to fill the affected side of 
the chest, and sometimes causing more or less 
enlargement. 

2. An accumulation of liquid partially filling the 
affected side of the chest, the quantity being either 
small, moderate, or considerable. 



32 INTRODUCTION 

3. Fibrinous exudation on the pleural surface. 

4. Air with liquid within the pleural cavity, and 
perforation of lung. 

5. Air without liquid in the pleural cavity. 

6. Solidification of lung, either complete or approxi- 
mating to completeness. 

7. Solidification of lung, slight or moderate in 
degree. 

8. Dilatation of the air-vesicles, involving within 
them an abnormal accumulation of air. 

9. Extravasation of air within the pulmonary con- 
nective structure. 

10. Exudation within air- vesicles and bronchioles. 

11. Liquid within air- vesicles. 

12. Liquid (mucus, serum, pus, or blood) within 
bronchial tubes of large, medium, or small size. 

13. Liquid within bronchial tubes of minute size. 

14. Obstruction of the pulmonary bronchial tubes 
by mucus, swelling of the mucous membrane, and 
spasm of the bronchial muscular fibres. 

15. Obstruction of larynx, trachea, or bronchi 
exterior to the lungs, by plugs of mucus or foreign 
bodies. 

16. Obstruction of the trachea or a primary bron- 
chus by aneurismal or other tumors. 

17. Dilatation of bronchial tubes, cylindrical or 
sacculated. 

18. Pulmonary cavities. 

19. Tumor within the chest. 

20. Diaphragmatic hernia. 



CHARACTERS OF HEALTHY AND MORBID SIGNS 33 



THE DISTINCTIVE CHARACTERS OF HEALTHY 
AND MORBID SIGNS 

For the practice of auscultation and percussion it is 
essential to be able to recognize the signs, severally, 
which represent the different physical conditions in 
health and disease. It is essential to distinguish the 
morbid from the healthy signs, and to discriminate 
from each other, severally, the signs of disease. The 
recognition and discrimination of signs require knowl- 
edge of the distinctive characters belonging to each 
of them. In entering upon the study of the signs, 
therefore, it is a necessary requirement to know whence 
their distinctive characters are derived. To this 
point of inquiry the attention of the student is now 
invited. 

The signs being sounds, they are to be recognized 
and discriminated in the way in which we practically 
recognize and discriminate other sounds. It is not 
necessary, in order to do this, to study the science 
of acoustics. In becoming familiar with other sounds, 
for example, musical notes produced by different instru- 
ments, or the varieties of the human voice, we do 
not have recourse to that science. It suffices for all 
practical purposes to contrast the sounds obtained 
by auscultation and percussion with reference to very 
simple and obvious differences; and, yet, it is 
necessary to understand very clearly in what these 
differences consist, or, in other words, the sources 
of the distinctive characters of these sounds. The 
3 



34 INTRODUCTION 

more important of the differences between the sounds 
obtained by auscultation and percussion relate to 
intensity, pitch, and quality. The distinctive charac- 
ters of most of the signs are derived from these three 
sources. In becoming practically acquainted with the 
signs, they are to be contrasted as regards intensity, 
pitch, and quality, precisely as we would bring other 
sounds into contrast in these three aspects. The 
distinctive characters of the signs, severally, are 
especially derived from their differences in these 
respects. The distinctions expressed by the terms 
intensity, pitch, and quality are, therefore, to be 
made clear. 

Differences in the intensity of sounds are easily 
understood. One sound is more intense than another 
sound when it is simply louder, and varying degrees 
of intensity are expressed by such terms as feeble or 
weak and loud, to which may be prefixed adjectives 
of quantity, such as very, moderate, etc. This is all 
that need be said with reference to the first of the 
three aspects under which sounds are contrasted. 
It will be seen hereafter that intensity is an essential 
element in the distinctive characters of certain of 
the signs. 

Differences in the pitch of sounds are easily under- 
stood by those who have given any attention to music. 
The differences are expressed by the terms high and 
low, to which may be prefixed words denoting a greater 
or less degree of highness or lowness. A nice appre- 
ciation of variations in the pitch of musical notes, 
requires what is known as a " musical ear;" but a 



CHARACTERS OF HEALTHY AND MORBID SIGNS 35 

very nice appreciation is not essential in comparing, 
as regards pitch, the sounds studied in auscultation 
and percussion. For the most part, these sounds are 
not musical notes; nevertheless, differences in pitch 
are readily perceived. A musical ear is undoubtedly 
an advantage in readily distinguishing differences in 
pitch; but it is by no means a sine qua non. For those 
who have given no attention to music, some difficulty 
may be at first experienced in judging correctly of 
differences in this regard; but the difficulty disap- 
pears after a little practice. Differences in pitch now 
enter pretty largely into the distinctive characters 
of physical signs; but by Laennec, and those who 
immediately followed him, comparatively little atten- 
tion was paid to the study of signs with reference 
to these differences. The writer was led to engage 
in this study more than a quarter of a century ago, 
and hereafter, in giving an account of the different 
signs, he will claim to have been the first to have 
clearly indicated certain characters from this source. 1 
Differences relating to quality are apt, at first, to 
be confounded with those relating to pitch; hence 
the distinction between pitch and quality must be 
clearly understood. We may say of the quality of 
a sound, that it embraces whatever is not embraced 
in the terms intensity and pitch. This is true as a 
general statement. The sense of the term quality, 
in distinction from intensity and pitch, may be most 

1 Vide Prize Essay on "Variations of Pitch in Percussion and 
Respiratory Sounds, and their Application to Physical Diag- 
nosis." Transactions of the American Medical Association, 1852. 



36 INTRODUCTION 

readily made clear by an illustration. Let it be sup- 
posed that we bear the notes of an instrument which 
is unseen — the performer, for example, being in another 
room. We recognize at once the instrument by the 
notes, provided it be one with which we are familiar, 
such as a violin, a flute, a clarionet, etc. We do not 
need to see the instrument; we recognize it by the 
sounds. Now, how do we recognize it? Certainly 
not by the intensity of the sounds; it matters not 
whether these be loud or weak, so that we hear them. 
Certainly not by the pitch; for if a piece of music 
be performed, we get both high and low notes. We 
recognize the instrument by the quality of the sounds. 
Each musical instrument, owing to its peculiarity of 
construction, yields sounds which are peculiar to it; 
and after we have become familiar with the quality 
of sounds peculiar to an instrument, we immediately 
thereby recognize it. Precisely in the same way we 
may recognize certain sounds produced by auscultation 
and percussion in health and disease. The signs differ 
in quality according to the physical conditions which 
they severally represent; and differences in quality 
will be found hereafter to constitute essential and 
obvious distinctions by which the signs of health and 
disease are recognized and discriminated. This is 
a source ot some of the most distinctive of the char- 
acters of certain of the physical signs. 

Of the peculiar quality of any particular sound 
one can form no definite idea otherwise than by direct 
observation. That is to say, no one could describe 
to another the peculiar quality of a particular sound 



CHARACTERS OF HEALTHY AND MORBID SIGNS 37 

so that it would be clearly apprehended without the 
sound having been heard. Imagine the attempt to 
describe the sound of a violin to a person who had 
never listened to the notes from that instrument — it 
would be impossible to give a correct idea of it in 
language. The only way in which an approximate 
idea could be conveyed in words, would be by com- 
paring the quality to that of some other instrument to 
the notes of which there was some resemblance — that 
is, by analogy. To attempt to describe the quality of 
sounds to one who had never heard them would be 
like describing colors to one blind. It will be seen 
hereafter that the quality of certain sounds obtained 
by auscultation and percussion is peculiar to them, 
and their distinctive characters in this respect can be 
known only by direct observation; they cannot be 
learned by means of any verbal description, nor by 
any comparisons — that is, by analogy. 

Appreciable variations in the quality of sounds 
are infinite. This may be illustrated by the human 
voice. Almost every person may be recognized from 
a peculiar quality of the voice by one who is familiar 
with it; and the voices of thousands of persons, if 
compared, would present shades of difference — in 
fact, as is well known, it is extremely rare for the 
voices of any two persons to be so nearly identical 
in quality that they cannot be distinguished from 
each other. As the diversity in quality of different 
sounds cannot be described, so they can only be 
designated by names which are significant from cer- 
tain resemblances. Terms based on analogies which 



38 INTRODUCTION 

are used to denote qualities of the sounds furnished 
by auscultation and percussion are the following: 
rough, harsh and rude, soft, blowing, hollow, musical, 
moist, dry, bubbling, gurgling, crackling, clicking, 
rubbing, grating, creaking, tubular, cracked metal, 
sibilant or whistling, sonorous or snoring. All these 
names owe their significance to resemblances to other 
sounds. One sound furnished both by auscultation 
and percussion has a quality which is sui generis, 
and the term used to distinguish it is derived from 
its source, namely, the vesicular resonance, and the 
vesicular murmur of respiration. 

In addition to intensity, pitch, and quality as 
sources of the distinctive characters of the signs 
furnished by auscultation and percussion, there are 
some other points of difference, namely, the duration 
of certain sounds; their continuousness or otherwise; 
their apparent nearness to, or distance from, the ear; 
their rhythmical succession, and their strong resem- 
blance to particular sounds, such as the bleating of 
the goat, the chirping of birds, etc. These points of 
difference are important, although less so than those 
relating to intensity, pitch, and quality. 

The study of the different sounds furnished by 
auscultation and percussion, with reference to dis- 
tinctive characters relating especially to intensity, 
pitch, and quality, distinct signs being determined 
from points of difference as regards these characters, 
may be distinguished as the analytical method. It 
may be so distinguished in contrast with the deter- 
mination of signs deductively, taking as a standpoint 



SIGNIFICANCE OF THE PHYSICAL SIGNS 39 

either the physical conditions incident to diseases 
or the sounds. If we undertake to decide, a priori, 
that certain sounds must be furnished by auscultation 
and percussion when certain conditions are present 
we shall be led into error; and so, equally, if we under- 
take to conclude from the nature of the sounds that 
they must represent certain conditions. The only 
reliable method is to analyze the sounds with reference 
to differences relating especially to intensity, pitch, 
and quality, and to determine different signs by these 
differences, the import of each of the signs being then 
established by the constancy of association with 
physical conditions. It is by this analytical method 
only that the distinctive characters of signs can be 
accurately and clearly ascertained. This is to be borne 
in mind by the student in physical exploration. He 
is to become acquainted with the different signs, and 
to recognize them in practice, by acquiring a knowl- 
edge of the distinctive characters of each, as derived 
mainly from differences relating to intensity, pitch, 
and quality. The individuality of the signs, severally, 
can rest on no other solid basis. 



THE SIGNIFICANCE OF THE SIGNS AS REGARDS 

THE PHYSICAL CONDITIONS WHICH THEY 

SEVERALLY REPRESENT 

Knowledge of the significance of the physical signs 
is the complemental requirement in the study of 
auscultation and percussion. For the successful 



40 INTRODUCTION 

employment of these methods, in addition to the 
recognition of each sign by its distinctive characters, 
must be known its significance, that is, the physical 
condition which it represents. In this respect the 
signs may be compared to the substantives in lan- 
guage, each having a definite meaning. The signs 
furnished by these methods may be said to consti- 
tute a language with a very small vocabulary; or, 
taking as the standpoint the things signified, the 
different physical conditions are expressed by means 
of the signs. 

It is to be noted that the significance of the morbid 
signs relates immediately, not to diseases, but to the 
physical conditions incident thereto. Very few signs 
are directly diagnostic of any particular disease. 
They represent conditions not peculiar to one, but 
common to several, diseases. Thus, solidification 
of lung exists in pneumonia, phthisis, pleurisy with 
effusion, collapse, and pulmonary neoplasm; now,* 
certain signs tell us that this morbid condition exists, 
together with its situation, its degree, and its extent. 
With this information the diagnosis of the disease 
is made by connecting with it pathological laws, 
together with the history and symptoms. The student 
in physical exploration should by no means imagine 
that, for the diagnosis of diseases, exclusive reliance 
is to be placed on the signs; they are always to be 
taken in connection with pathological laws, the his- 
tory, and the symptoms. Disconnected from these, 
the signs would often lead to error, and it is no dis- 
paragement to physical diagnosis that its reliability 



REGIONAL DIVISIONS OF THE CHEST 41 

depends on other facts than those which belong 
exclusively to it. 

To repeat a statement already made more than 
once, the significance of the signs, as regards the 
conditions which they severally represent, is based 
on the constancy of their association with the latter, 
our knowledge of this association being derived from 
examinations during life and after death. 

REGIONAL DIVISIONS OF THE CHEST 

Before entering on the study of physical explora- 
tion, the student should become acquainted with the 
divisions of the surfaces of the anterior, posterior, 
and lateral aspects of the chest into circumscribed 
spaces which are called regions. These divisions, 
deriving their boundaries and names from their 
anatomical relations, are sufficiently simple. 

Anteriorly the chest is divided into regions as 
follows: The supra- or post-clavicular region extends 
from the clavicle upward a short distance, correspond- 
ing to the variable height to which the lung rises 
above this bone. The clavicular region embraces the 
space occupied by the clavicle. The infra-clavicular 
region embraces the space between the clavicle and 
the third rib. The mammary region is bounded above 
by the third and below by the sixth rib, and the 
inframammary region is the portion of the chest 
below the sixth rib. 

Posteriorly the divisions are into the scapular, 
the infra-scapular, and inter-scapular regions. The 



42 



INTRODUCTION 

Fig. 1 




The horizontal lines indicate the boundaries of the regional divisions on the 
anterior aspect of the chest. The vertical lines are the midsternal, or anterior 
median line; the right and left sternal lines, the right and left parasternal lines, 
and the right and left midclavicular lines (the latter representing a term 
formerly and less accurately used, namely, the mammillary line). The oblique 
dotted lines indicate the interlobar fissures: ab, ac, cd t and bd, boundaries of 
superficial cardiac space; ik, outer boundars*- of deep cardiac space; ce, lower 
boundary of right lung; df, lower boundary of left lung; gh, upper boundary of 
right and left lung; Im, lower boundary of hepatic flatness; pq, upper boundary 
of hepatic dulness; no, lower boundary of the stomach moderately distended. 



REGIONAL DIVISIONS OF THE CHEST 43 



scapular region is the space occupied by the scapula 
and is divided by the spinous ridge into the upper 



Fig. 2 




The longitudinal and vertical lines indicate the regional divisions on the 
posterior aspect of the chest. The vertical lines are called the vertebral or 
posterior median line, and the right and left scapular lines: ab, lower bound- 
ary of lungs; cd, lower limit of expansion of lungs; ef, interlobar fissures; h, 
spleen; i, lower boundary of liver; k, left kidney; I, right kidney; mn, upper 
boundary of left and right lung. 



44 



INTRODUCTION 



and lower scapular space. The infra-scapular region 
is the portion below a horizontal line intersecting 
the lower angle of the scapula. The inter-scapular 



Fig. 3 




t The horizontal line indicates the regional division of the lateral aspect of 
the chest: ab, lower boundary of right lung; cd, lower boundary of hepatic 
flatness; ef, upper boundary of hepatic dulness; k, border of kidney: gb, lower 
limit of expansion of lung; xz, fissure between posterior or lower lobe and the 
upper and middle lobes in front; my, fissure between the upper and middle 
lobes; np, is the right midaxillary line. 



REGIONAL DIVISIONS OF THE CHEST 



45 



region is the space between the posterior margin of 
the scapula and the spinal column. 

Laterally there are two regions, namely, the axillary 



Fig. 4 




ab, boundary of hepatic flatness; cd, lower boundary of the left lung; e, U 
boundaries of spleen; Im, boundary of kidney; r, lower boundary of the stomach 
in moderate distention: np, left midaxillary line; xz, left interlobar fissure; 
cs, lower limit of expansion of lung. 



46 INTRODUCTION 

and the infra-axillary. The axillary region is the 
space above a horizontal line extending from the lower 
border of the mammary region, ?. e., the sixth rib. 
The infra-axillary region is the portion below the 
axillary region. 

The portion of the anterior surface occupied by 
the sternum is divided into the upper and the lower 
sternal region, the space above the sternal notch 
being the supra-sternal region. 

In order to become familiar with the foregoing 
regional divisions, it is recommended to the student 
to delineate them with a skin pencil on the chest of 
the living subject or a cadaver (Figs. 1, 2, 3, 4). 

It is advisable to study sections, extending from 
the surface to the centre of the chest, corresponding 
to the different regions, so as to become familiar with 
the relation of each section to the parts contained 
within it. An enumeration of the more important 
of the anatomical relations of the different regions 
is as follows: 

1. Supra-clavicular Region. — This is relative to the 
upper extremity or apex of the lung, which arises 
above the clavicle in different persons from half an 
inch to an inch and a half. The height is generally 
greater on one side, and this side is usually the left. 

2. Clavicular Region. — A small portion of the lung 
at or near the apex is contained in the section cor- 
responding to this region. 

3. Infra-clavicular Region. — The parts situated here, 
exclusive of the upper sternal region (vide No. 7), 
are the upper portion of the lung, and the extra- 



REGIONAL DIVISIONS OF THE CHEST 



47 



pulmonary bronchi. The difference between the 
primary bronchi, as regards direction, size, and length, 
are important points in the study of this section 
(Figs. 5, 6). 



Fig. 5 




A 



V 



Position of the trachea, main and proximal subdivisions of the bronchi in 
relation to the ribs and sternum. 

4. Mammary Region. — The differences between the 
two sides in the sections corresponding to this region 
are important. These differences relate especially 
to the precordia, and are involved in the physical 
diagnosis of enlargement of the heart. The commence- 
ment of the interlobar fissures is in this region. On 
the left side the fissure is between the fourth and fifth 



48 



INTRODUCTION 



ribs. On the right side the fissure between the upper 
and middle lobes begins at the fourth costal cartilage, 
and between the middle and lower lobes a short dis- 
tance below. The situation of the fissures, however, 
differs considerably during the acts of inspiration and 
expiration. The liver reaches the fifth rib on the right 
side. 

Fig. 6 




Position of the trachea, main and proximal divisions of the bronchi in relation 
to the ribs and vertebral column. 



5. Infra-mammary Region. — This region differs in its 
anatomical relations considerably on the two sides 
of the chest. On the right side the liver pushes upward 
the diaphragm nearly or quite to the upper boundary 
of the fifth rib. On the left side the section corre- 



REGIONAL DIVISIONS OF THE CHEST 49 

sponding to the region embraces, together with the 
anterior portion of the lower lobes of the lung, por- 
tions of the stomach, spleen, and the left lobe of 
the liver. The variable volume of the stomach at 
different times occasions considerable variations in 
the relative spaces occupied by these different parts. 

6. Supra-sternal Region. — This region is in relation 
to the trachea. 

7. The Upper Sternal Region. — The bifurcation of 
the trachea is beneath the sternum at the centre of 
a line connecting the second ribs. Below this line 
the lungs on the two sides are nearly in contact 
at the mesial line, covering the primary bronchi. 

8. Lower Sternal Region. — The sternum in this region 
covers a large portion of the right and a little of the 
left ventricle, lying behind the right in this region. 

9. Scapular Region. — The sections corresponding to 
this region contain the posterior portion of the upper 
lobe and a portion of the upper part of the lower lobe 
of the lung. At the upper part of the lower scapular 
space terminates the fissure separating the upper 
from the lower lobe. The line of this fissure pursues 
an oblique course to the fourth or fifth rib on the 
anterior aspect of the chest. 

10. Infra-scapular Region. — On the right side the lung 
extends from the upper boundary of this region to 
the eleventh rib, the liver lying in contact with the 
chest-wall up to the latter point. On the left side 
the section contains a portion of the spleen. 

11. Inter-scapular Region. — The trachea extends in 
this section to the fourth dorsal vertebra, where it 

4 



50 INTRODUCTION 

bifurcates. 1 Below this point on the two sides are 
situated the primary bronchi. 

12. Axillary Region. — The section corresponding to 
this region contains a portion of the upper lobe with 
large bronchial tubes. 

13. Infra-axillary Region. — This is in relation to the 
upper part of the liver on the right side, and on the 
left side to a portion of the spleen and stomach. 
The remainder of the section is occupied by lung. 

It is recommended to the student to become familiar 
with the sections corresponding to the different regions, 
by dissections for this purpose, and the study of 
anatomical illustrations (Figs. 1, 2, 3, 4). 

Asking the student's careful attention to the intro- 
ductory considerations which have been presented, 
auscultation and percussion in health and disease, 
and the physical signs involved in the diagnosis of 
diseases of the respiratory system and of the heart, 
will now be considered. 

1 The position of the trachea and bronchi in relation to the 
bony points of the thorax is probably more accurately indicated 
in the diagrams of Dr. Blake (Figs. 5 and 6; than in the text. 
Amer. Jour. Med. Sci., March, 1899. 



CHAPTER II 
PERCUSSION IN HEALTH 

Percussion with the fingers or with a percussor and pleximeter 
— The normal vesicular resonance on percussion; its distinc- 
tive characters relating to intensity, pitch, and quality — 
Variations in the characters of the normal vesicular resonance 
in different persons — Relations of the pitch of resonance to the 
vesicular quality — Tympanitic resonance over the abdomen — 
Variations of the normal resonance in the different regions of 
the chest — Enumeration of the regions in which the resonance 
on the two sides varies, and those in which it is identical in health 
— Influence of age on the normal resonance — Influence of the 
acts of respiration on the resonance — Rules in the practice of 
percussion. 

Percussion may be performed with either the fingers 
or artificial instruments. The fingers suffice for the 
study and in ordinary practice. Instruments are 
preferable only when it is desired to produce sounds 
to be heard at a distance, as in class illustrations, and 
when, from the number of patients to be percussed, 
as in dispensary or hospital practice, the frequent 
repetition of the blows renders the fingers tender and 
painful. The instruments are a pleximeter and a 
percussor. A good form of a pleximeter, and of a 
percussion hammer are illustrated in Figs. 7 and 8. 

When percussion is performed with the finger, the 
palmar surface of one or more of those of the left 
hand should be applied to the chest, with pressure 



52 



PERCUSSION IN HEALTH 



sufficient to condense the soft structures, and the 
blows are given with one or more of the fingers of the 
right hand bent at the second phalangeal joint so as 
to form a right angle. In giving the blows, the move- 
ments should be limited to the wTist-joint, the ends, 
not the pulp of the percussing fingers being brought 

Fig. 7 




Pleximeter. 

into contact with the dorsal surface of the finger or 
fingers applied to the chest. The percussing fingers 
should be withdrawn instantly the blow is given. 
The type of perfect percussion is the movement of 
the hammers when the keys of a piano-forte are struck. 



Fig. 8 




Percussion hammer. 

The force of the percussion should never be sufficient 
to give pain to the patient; generally either light or 
moderately forcible blows suffice. The requisite tact 
in the performance of percussion is acquired by a 
little practice. 

In percussing for the outlines of viscera lying close 



PERCUSSION IN HEALTH 53 

to the chest wall, light application of the pleximeter 
fingers, and a light stroke with the percussion finger 
gives best results. 

In percussing for deeply situated margins of viscera 
or, for example, areas of consolidation or cavities, the 
pleximeter finger can with advantage be applied 
more firmly, and the percussion stroke be slightly 
more vigorous. 

The first object in the study of percussion is to 
become acquainted with the characters which are 
distinctive of the sound obtained thereby from the 
healthy chest. For this object the percussion may 
be made either in the infra-clavicular region of either 
side, or in the infra-scapular region, the sound in these 
situations being louder than in other regions. Per- 
cussion being performed, a sound or resonance is 
produced. This sound or resonance is now to be 
analyzed with reference to characters derived from 
intensity, pitch, and quality. What are these charac- 
ters? The intensity will depend, other things being 
equal, on the force of the blow; the resonance is com- 
paratively feeble with a slight, and loud with a strong, 
percussion. Other circumstances affect the intensity 
irrespective of the force of the blow — namely, the 
volume of the lung, the elasticity of the costal cartil- 
ages, and the thickness of the soft parts which cover 
the chest. Owing to these circumstances, the intensity 
of the resonance is by no means similar, in the same 
situation, in all healthy persons; it is comparatively 
feeble in some and loud in others. There is nothing 
distinctive of this normal resonance to be derived 



54 PERCUSSION IN HEALTH 

from intensity, and we say, therefore, that the intensity 
is variable. 

What is the pitch of this normal resonance? The 
pitch of a sound is always relative; and, comparing 
this resonance w T ith all the morbid signs obtained 
by percussion, it is lower in pitch. We say, there- 
fore, that the pitch of this normal resonance is low. 
The pitch, however, is found to vary in different 
healthy persons. 

What is the quality of this normal resonance? It 
has a quality which is peculiar to it. In this respect 
it is not identical with any sound produced other- 
wise than by percussion over healthy lung either 
within or without the chest. The quality cannot, there- 
fore, be learned by analogy, nor can it be described; 
it can only be appreciated by direct observation. 
The peculiar quality is due to the fact that the reso- 
nance is from air contained in the pulmonary vesicles. 
This arrangement causes the peculiar quality, just 
as the construction of any particular musical instru- 
ment causes the quality of tone peculiar to the instru- 
ment; hence, as it is convenient to give the quality 
a name, we call it the vesicular quality. This quality 
is not equally marked in all healthy persons, being, as 
a rule, more marked in proportion to the intensity 
of the resonance. 

This vesicular quality, as just noted, is peculiar to 
the pulmonary resonance. An approximative repre- 
sentation of it is obtained by percussing either a 
sponge or a loaf of bread. The latter gives a closer 
imitation than the former. Each of these articles 



PERCUSSION IN HEALTH 55 

affords a resemblance to the vesicular quality of reso- 
nance, for the reason that it contains air in an infinite 
number of small spaces, in this regard resembling the 
lungs. In order to represent this sign by percussing 
a loaf of bread, the loaf should be covered with a 
napkin, in order to lessen the noise produced by the 
contact of the finger or the percussor, and thus to 
elicit better resonance from the air contained in the 
interstices of the loaf. The upper crust stands in place 
of the thoracic wall. The resonance elicited illustrates 
the lowness of pitch with a pretty close approach to the 
peculiar quality of the normal vesicular resonance. 

The normal resonance, then, obtained by percussion 
may be thus defined : 

A resonance of variable intensity, low in pitch and 
having a peculiar quality called vesicular. The word 
vesicular is frequently embraced in the name of this 
healthy sign; it is also called the normal resonance, the 
normal pulmonary resonance, or the normal vesicular 
resonance. The last of those names is to be preferred. 

The normal vesicular resonance on percussion, as 
has been seen, is not uniform in all healthy persons; 
not only is its intensity variable, but it varies in pitch 
and in the amount of vesicular quality. This may be 
easily illustrated by percussing successively in the 
same situation, and with the same force, a series of 
persons who are assumed to be free from disease. 
Is there not in this fact an obstacle in practically 
determining this healthy sign? The fact occasions 
no embarrassment for this reason: we determine, 
in each case, that the resonance is normal by a com- 



56 PERCUSSION IN HEALTH ' 

parison of the two sides of the chest, percussing in 
corresponding situations on the two sides and with 
the same force. There is no ideal standard of the 
normal vesicular resonance, but, by comparing the 
two sides of the chest, the standard of health proper 
to each person is obtained. The laws of disease are 
such that, for all practical purposes, the standard of 
health is in this way almost always available. Not- 
withstanding the variations within the range of health, 
the lowness in pitch and the vesicular quality are 
sufficiently distinctive of this normal sign as compared 
with the morbid signs. 

The pitch of the vesicular resonance and its vesic- 
ular quality are in a uniform relation to each other; 
that is, the conditions giving rise to the peculiar 
quality also render the pitch low. In proportion as 
the vesicular quality is marked, the pitch is lowered, 
and, conversely, with diminution of the vesicular 
quality the pitch is relatively higher. This relation 
between the pitch and quality will be found to hold 
good in the resonance modified by disease as well as 
in health. Another relation may be here stated — 
namely, whenever, in health or disease, a tympanitic 
quality is combined with the vesicular, and in propor- 
tion as the former predominates, the pitch of the 
resonance is raised. 1 

1 That the pitch of tympanitic resonance is invariably higher 
than the pitch of vesicular resonance, cannot be accepted, in 
view of the fact that relaxed sheep or calf lung, outside the 
body, will give a lower note than the same lung when moder- 
ately distended with air; and of this fact the student may easily 
convince himself. — Ed. 



PERCUSSION IN HEALTH 57 

The pitch and quality of the normal vesicular 
resonance may be readily illustrated by percussing 
successively over the chest and the abdomen. The 
different sections of the alimentary canal generally 
containing more or less gas, a resonance is obtained 
by percussion over the abdomen. This resonance is, 
of course, devoid of the vesicular quality; in con- 
tradistinction to the latter, its quality is called tym- 
panitic. This tympanitic resonance is not uniform 
in all parts of the abdomen, but everywhere the 
quality is tympanitic, that is, non-vesicular, and the 
pitch is everywhere higher than that of the normal 
vesicular resonance. The tympanitic resonance over 
the stomach is generally high in pitch, and frequently 
has a ringing or metallic intonation. The gastric 
tympanitic resonance recognized by these characters, 
will be found to be involved frequently in sounds 
produced by percussing over the chest. Gas in the 
cecum gives a still higher pitch of resonance. Ove 
the colon the resonance is lower than over the cecum 
and stomach, and it is still lower over the small intes- 
tines. In all these situations, bringing the tympanitic 
in contrast with the normal vesicular resonance, the 
peculiar quality of the latter and its lowness of pitch 
are rendered apparent. The term tympanitic reson- 
ance will be found to enter into the names of two of 
the morbid signs obtained by percussion. 

Having studied the characters of the normal vesic- 
ular resonance, and become practically familiar 
with them by percussing different healthy persons, 
the student should study the variations which this 



58 PERCUSSION IN HEALTH 

resonance presents in the different regions of the 
chest. In doing this he acquires more and more 
tact in the performance of percussion, and becomes 
more and more familiar with the characters in general 
of the normal vesicular resonance. 

Supra- or Post-clavicular Region. — The resonance 
here varies much in intensity in different persons. 
The vesicular quality is most marked in the central 
portions. Toward the sternal extremity the reson- 
ance acquires a tympanitic quality irom the prox- 
imity to the trachea; it becomes vesiculotympanitic, 
a term which will be applied to one of the morbid 
signs. In the supra-clavicular region resonance is to 
be found extending from three-fourths to two inches 
above the upper border of the clavicle. 

Clavicular Region. — Near the sternum the reson- 
ance is somewhat tympanitic from the proximity 
to the trachea. At the central portion the vesicular 
quality is more or less marked, and the intensity is 
diminished at the acromial extremity. 

Infra-clavicular Region. — The resonance in this region 
is more intense than elsewhere, except in the axillary 
and the infra-scapular regions. The vesicular quality 
is combined with a tympanitic quality toward the 
sternum, the latter being derived from the primary 
and secondary bronchi. As always when the vesicular 
and the tympanitic quality are combined, the pitch 
is raised. This combination in health and disease is 
recognized by the intensity, pitch, and quality. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular region, 



MAMMARY REGION 59 

owing to the presence of the scapula and its muscles. 
In proportion as the intensity is less, the vesicular 
quality is less marked. The resonance in health, 
however, is quite sufficient for morbid signs to be 
available in this situation. In the supra-scapular 
region resonance is to be found for a distance of two 
to three and a quarter inches along the upper border 
of the trapezius muscle. 

Inter-scapular Region. — The resonance in this region 
is weak in comparison with other regions, except 
the scapular, owing to the muscles which here cover 
the chest. In the upper part of the region the reson- 
ance is somewhat tympanitic from the relation to the 
trachea and bronchi. 

Mammary Region. — The right and the left mam- 
mary region are to be studied with reference to dif- 
ferences relating to the liver and the heart. On the 
right side, from the fourth rib downward, the resonance 
is diminished, the dome or upper surface of the liver 
extending up to this height. At or a little below the 
lower border of this region on the mid-clavicular line, 
that is, a vertical line passing through the middle 
of the clavicle, resonance ceases, the lower lobe of the 
right lung not extending below this point. Between 
the third and fifth ribs on this side near the sternum 
the resonance is diminished from the presence of a 
portion of the right auricle and ventricle. On the 
left side the resonance is dininished within the pre- 
cordial space. This space extends vertically from 
the third rib to the fifth intercostal space, and hori- 
zontally from the sternum to a point at or a little 



60 PERCUSSION IN HEALTH 

within the mid-clavicular line. The resonance is 
considerably diminished within what is called the 
superficial cardiac space. This space may be repre- 
sented by a right-angled triangle, the right angle 
formed by a vertical line drawn from a point on the 
median line intersected by a horizontal line connect- 
ing the fourth ribs, and a horizontal line intersecting 
the point of apex-beat in the fifth intercostal space; 
an oblique line drawn from the centre of the sternum 
on a level with the fourth rib and the point of apex- 
beat forms the hypotenuse of the right-angled triangle. 
This oblique line is, in fact, a curved, not a straight, 
line (vide Fig. 1, p. 41), the convexity looking to the 
left side. Practically, however, it is near enough to 
accuracy to consider it the hypotenuse of a right- 
angled triangle. Within this space the heart is in 
contact with the thoracic wall. Without this space and 
within the precordia the heart is covered with lung, 
and the resonance on percussion is less diminished. 
It is a useful exercise for the student to observe the 
diminution of the area of the superficial cardiac space 
by a forced inspiration, as determined by percussion. 
Aside from the presence of the heart and the convex 
extremity of the liver, the resonance over the mam- 
mary is less than in the infra-clavicular region, being 
diminished by the pectoral muscle, which varies 
considerably in bulk in different persons, and in women 
by the mammary gland, the size of the latter varying 
very much in different women. The development of 
the mammae, however, is never so great as to preclude 
the useful employment of percussion in this region. 



INFRA-MAMMARY REGION 61 

Infra-mammary Region. — In this region, as in the 
region above it, the two sides present notable differ- 
ences owing to the situation of the organs below the 
diaphragm. On the right side, over the greater part, 
and sometimes the whole of this region, resonance is 
wanting, that is, percussion gives flatness. It is easy 
to delineate the boundary between the lower border 
of the right lung and the liver, or, as it is called, the 
line of hepatic flatness. It is also easy to distinguish 
above this line the height to which the upper surface of 
the liver extends, or, as it is called, the line of hepatic 
dulness, 1 The situation of both these lines varies 
considerable in different healthy persons. The distance 
between the two lines is from one to two inches. Both 
lines are affected considerably by a forced inspiration 
and a forced expiration. A forced inspiration depresses 
the line of flatness about one and one-half inch. A 
forced expiration causes the line to rise from two 
and one-half to five and one-half inches. The distance, 
therefore, between this line at the end of a forced 
expiration and at the end of a forced inspiration 
varies from four to seven inches. With reference 
to the practice of percussion, as well as for the pur- 
pose of verification, these points should be studied. 
Not infrequently percussion over the right infra- 
mammary region yields a tympanitic resonance due 
to the distention with gas of the transverse colon. 

1 It is apparent, from the use of the £-ray in physical examina- 
tion, that neither the accuracy nor the value of the line of hepatic 
dulness is such as to justify attempts at its determination by 
percussion. The lung-liver boundary and the liver edge are 
easily determined and of decided value. — Ed. 



62 PERCUSSION IN HEALTH 

On the left side, the resonance in this region varies 
in different persons, in the same persons at different 
times, and in different portions of the region at the 
same time, the variations depending on the organs 
below the diaphragm. Flatness is caused by the 
extension of the left lobe of the liver into this region 
about three inches to the left of the median line. 
The left portion of the region is in relation to the 
spleen, an organ which varies considerably in size 
in health as well as in disease, its average dimensions 
being about four inches in length and three inches in 
width. Between the spleen and the liver lies the 
stomach, the volume of which is constantly fluctu- 
ating, owing to its varying solid, liquid, and gaseous 
contents. Distention of the stomach with gas occa- 
sions a tympanitic resonance which frequently is 
transmitted above into the mammary region in health 
as well as in disease. The space corresponding to the 
spleen is determined by the vesicular resonance above 
and the tympanitic resonance below, the latter bound- 
ary, however, not being very reliable on account of 
the ready conduction of tympanitic resonance for a 
certain distance. 

The spleen lies in the left hypochondrium between 
the ninth and eleventh ribs, its long axis corresponding 
to the tenth rib. Its posterior extremity is about 
one and one-half inches from the spinal column; its 
anterior pole reaches to the middle or at most to the 
anterior axillary line. 

The upper posterior third, being covered by lung is 
inaccessible to percussion. 



STERNAL REGIONS 63 

The remainder, lying against the chest wall, unless 
forced away by intervening intestines, is found to 
give a dulness on examination in sitting, standing, 
or right and oblique recumbent position. The lung 
border, intersecting the eighth and ninth ribs, is the 
upper limit of splenic dulness; the anterior limit is 
rarely as far forward as the anterior axillary line; the 
lower limit is at the eleventh rib; posteriorly the 
dulness merges into that of the lumbar muscles. 

Between the anterior splenic dulness and the left 
end of liver dulness is a half-moon shaped space 
(Traube's space) of tympany, which is of importance 
in the diagnosis of left-sided pleural exudates. 

The distention of the stomach with solid or liquid 
contents, of course, occasions flatness. The study 
of the infra-mammary regions with reference to the 
variations in resonance arising from the relations to 
the organs below the diaphragm is of much -utility 
from the practice, as well as the knowledge, which 
it involves. The exercise of endeavoring to define 
the boundaries of these different organs in healthy 
persons will be of great service to the student in 
acquiring tact in percussion, and in discriminating 
differences in the sounds obtained by this method. 

Sternal Regions. — In the upper sternal region, that 
is, above the lower margin of the second rib, the 
resonance is non- vesicular, being derived from air in 
the trachea above the point of bifurcation. Being 
non-vesicular, it is, of course, tympanitic, inasmuch 
as the resonance is always tympanitic in quality if 
wholly devoid of the vesicular quality. Between 



64 PERCUSSION IN HEALTH 

the second and third ribs, the inner borders of the 
two lungs approximating, the resonance has a vesic- 
ular quality more or less marked; but owing to 
the remnant of the thymus gland, together with 
adipose substance, and the presence of the large 
vessels, the resonance is not intense in this situation. 
Below the third rib the resonance has modifications, 
due to the combination of several different organs 
situated beneath the lower sternal region. On the 
right side of the mesial line is the inner border of the 
right lung, the greater part of the right and a por- 
tion of the left ventricle of the heart lying beneath; 
a portion of the liver extends into the lower part 
of this region, and a portion of the stomach when 
distended. The resonance thus varies in different 
situations, and often presents a mixed character. It 
is a useful exercise to endeavor to define by percussion 
the boundaries of the several organs which are here in 
juxtaposition. The bone of the sternum has a char- 
acteristic note of its own which modifies all percussion 
sounds obtained upon it, whether there be resonance 
or extreme dulness. 

Infra-scapular Regions. — The resonance below the 
scapula is intense as compared w r ith that over the 
scapula, and the vesicular quality is marked. The 
resonance extends to the eleventh rib, which is the 
lower boundary of the lung. On the right side, at or 
near this point, is the line of hepatic flatness, hepatic 
dulness extending from one to two inches above 
this line. The line of hepatic flatness and of hepatic 
dulness is lowered from one to two inches by a deep 



LATERAL REGIONS 65 

inspiration, and raised by a forced expiration. On 
the left side the resonance may receive a tympanitic 
quality from the presence of gas in the stomach. 

Lateral Regions. — In these regions the resonance 
is relatively intense, and notably vesicular. On the 
right side the line of hepatic flatness is at the eighth 
rib, hepatic dulness extending above this line, as in 
front and behind. On the left side the resonance 
may be rendered somewhat dull by the presence of 
the spleen, but it often has a tympanitic quality from 
the presence of gas in the stomach. 

As has been stated, the normal vesicular resonance 
is not in all persons identical as regards intensity, 
pitch, and quality. There is, therefore, no fixed 
standard in these respects by which we can deter- 
mine whether the resonance be normal or not. The 
standard proper to each person is to be ascertained 
by a comparison of the two sides of the chest; each 
person, in other words, furnishes his own standard ,of 
health. But it is to be observed that all the regions 
do not normally correspond in respect of the reso- 
nance on the two sides. In the following regions the 
resonance is notably dissimilar on the two sides: The 
mammary, the infra-mammary, the infra-axillary, 
and the infra-scapular. There is less disparity in the 
resonance on the two sides in the following regions: 
The supra-clavicular, clavicular, and infra-clavicular, 
the scapular and inter-scapular, and the axillary. 
In some of these regions, however, the resonance 
differs, and it is of practical importance to note the 
dissimilarity which thus belongs to health. This 
5 



66 PERCUSSION IN HEALTH 

statement applies especially to the infra-clavicular 
region, a region which, as will be seen hereafter, is 
of great importance with reference to the signs of 
phthisis. In this region the resonance on the left 
side is somewhat more intense, more vesicular, and 
lower in pitch than is the resonance on the right 
side; per contra, the resonance is less intense, less 
vesicular, and higher on the right side. This account 
of these points of disparity between the two sides 
is based on an analogy of recorded observations in 
a series of healthy persons. 1 The student should 
become practically familiar with the normal differ- 
ences between the two sides, and, in becoming so, 
the practical experience acquired in performing 
percussion will be of use. 

The normal resonance is affected by age. In early 
life, when the costal cartilages are flexible and elastic, 
the resonance is more intense and lower in pitch than 
in, old age, when the cartilages are rigid and the vesic- 
ular structure of the lung more or less atrophied. 

The resonance varies considerably in the different 
regions at the end of a full inspiration and at the 
end of a forced expiration. With regard to this dis- 
parity, the following is an extract from a work on 
physical exploration, published by the author in 1856: 

"The percussion sound may also be found to vary 
at different periods of an act of respiration in the 
same individual. The quantity of air contained 
within the air-cells, and consequently the relative 

1 Vide Physical Exploration of the Chest by the Author, 1856, 



LATERAL REGIONS 67 

proportion of air and solids, are by no means equal 
after a full inspiration and after a forced expiration. 
The difference in lung expansion may occasion an 
appreciable disparity in resonance, according as the 
percussion is made at the conclusion of a full inspira- 
tion or of a forced expiration. The disparity is not 
appreciable uniformly in different persons. This 
fact I have ascertained by noting the results of exam- 
inations made with reference to the point. When 
it does exist, it usually consists, contrary to what 
might perhaps have been anticipated, and the reverse 
of what is usually stated in works on physical explora- 
tion, in diminished resonance and elevation of pitch 
at the conclusion of inspiration. This is probably 
to be explained by the greater degree of tension of 
the lungs and thoracic walls produced by inspiration 
voluntarily prolonged and maintained — a condition 
presenting physical obstacles to sonorous vibrations 
more than sufficient to counterbalance the increased 
proportion of air within the cells. It is a curious 
fact, worthy of notice, that the two sides of the chest 
are not always found to be affected equally as regards 
the percussion sound, at the conclusion of a full 
inspiration, contrasted with that after a forced expira- 
tion. I have observed the contrast to be more striking 
on the right than on the left side; and in one instance 
on the left side, the resonance was less intense and 
somewhat tympanitic after a full inspiration, while 
on the right side the opposite effect was produced 
and the sound became quite dull after a forced expira- 
tion. In view of these variations in a certain propor- 



68 PERCUSSION IN HEALTH 

tion of instances incident to different periods of a 
single act of respiration, in some cases of disease in 
which it is desirable to observe great delicacy in the 
correspondence of the two sides, pains should be taken 
to percuss corresponding points at a similar stage 
of respiration, and the close of a full inspiration is, 
perhaps, the period to be preferred. Ordinarily, the 
liability to error from this source is obviated, either 
by repeating a series of strokes, first on one side and 
next on the other, or by percussing both sides repeat- 
edly in quick succession, in order mentally to obtain 
the average intensity and other characters of the 
sound during the successive stages of a respiration. 
The instances of disease, however, are exceedingly rare, 
in which such nicety of discrimination is important." 

There are two variations in methods of percussion 
which are found to assist in determining the bound- 
aries of solid viscera and cavities: A, the so-called 
auscultatory percussion, which consists in applying 
the stethoscope over an area to be outlined, as over 
the precordium, and then by light percussion (or even 
delicately stroking or scratching the skin), approach- 
ing the stethoscope from all directions, noting the 
sudden change in intensity of the conducted sound 
as the border of the underlying viscus is reached. 
This method is of service also in outlining the borders 
of the stomach; B, the so-called threshold percussion 
of Goldscheider which consists in light percussion 
upon the second phalangeal joint of the bent plex- 
imeter finger, the tip only of the finger being applied 
to the chest. By using only the interspaces and also 



RULES IN THE PRACTICE OF PERCUSSION 69 

limiting as finely as this the point of application of the 
stroke, often very precise limits of the heart may be 
determined. 



RULES IN THE PRACTICE OF PERCUSSION 

1. Prior to a comparison of the two sides of the 
chest, as regards the resonance on percussion, either 
in health or disease, an examination by inspection 
should be made, in order to determine whether 
there be any deviation from the normal conforma- 
tion. In what has been stated concerning percussion 
in health, it is assumed that the chest is symmetrical. 
Want of symmetry may be due to congenital deform- 
ities, and to those caused by rachitis, chronic pleurisy, 
curvature of the spine, and injuries. Any deviation 
from the normal conformation will affect more or 
less the resonance in corresponding regions on the two 
sides. Due allowance is to be made for want of sym- 
metry in determining morbid signs, and often the 
existence of these cannot be determined with posi- 
tiveness w r hen there is considerable deformity. The 
signs obtained by auscultation are less affected by 
want of symmetry than those obtained by percussion. 

2. Attention to the position of the person exam- 
ined is important with reference to the normal sym- 
metry of the chest. If the person be standing or 
sitting, the position should be upright and the shoulders 
brought to a level. A little inclination of the body 



70 PERCUSSION IN HEALTH 

to one side, or a depression of one shoulder, will be 
found to affect perceptibly the normal resonance 
when the two sides are compared. If the body be 
recumbent, it should be as nearly as possible on a 
level plane. In examining a patient in the lateral 
recumbent position, the side which is uppermost 
should be examined and the patient turned then to 
the other side, for reliable comparison between the 
two sides in percussion and auscultation cannot other- 
wise be made. These conditions are indispensable 
for a nice comparison of the two sides either in health 
or disease. 

3. In making a nice comparison, the person who 
percusses should be, as nearly as possible, either in 
front or behind the person percussed. Percussion 
made by one standing or sitting by the side of the 
person percussed is almost certain to produce disparity 
in resonance. 

4. Percussion made successively on one side and 
the other side, must be in all respects the same in 
regard to the mode, the force of the blow, and the 
situation. A light percussion on one side and a strong 
percussion on the other side will, of course, cause 
a disparity in the intensity of resonance. The per- 
cussion must be made in succession at points as 
nearly as possible equidistant from the median line, 
and from the summit or base of the chest. With 
reference to great nicety, the percussion, if made on 
the rib or intercostal space on one side, must be made 



RULES IN THE PRACTICE OF PERCUSSION 71 

on the rib or intercostal space on the other side. Great 
nicety of comparison also requires that if the per- 
cussion be made on one side during the act of inspira- 
tion it should be made on the other side during this 
act. The signs of disease, however, are generally so 
well marked that very close attention to these points 
is not necessary. 

5. A series of blows in rapid succession (five or seven) 
is to be preferred to one or two, in practising percus- 
sion, difference in intensity, pitch, and quality being 
thereby better appreciated. 

6. Percussion may be made lightly or forcibly the 
former being called superficial, and the latter, deep 
percussion. With light blows the resonance comes 
from the superficies of the lung and from within a 
limited area. With forcible blows the resonance is 
from a greater depth and a wider space. The result 
of these different modes of practising percussion may 
be illustrated within the precordia in health. Compar- 
ing the resonance over the superficial cardiac space 
with that in a corresponding situation on the right 
side, dulness is more marked with light than with 
forcible blows, the resonance from the latter coming 
from a wider area. On the other hand, comparing 
the resonance over the deep cardiac space, dulness 
is more marked with forcible than with light blows, 
owing to the presence of lung between the heart and 
the walls of the chest. This rule is of importance 
in its application to percussion in disease. 



72 PERCUSSION IN HEALTH 

7. Percussion over the anterior portion of the 
chest, the person percussed leaning against a door, 
a board partition, or a lathed wall, gives an increased 
intensity of resonance. It is often useful to resort 
to this procedure in the practice of percussion. 1 

8. In percussing over the posterior portion of the 
chest it is important that the scapulae be drawn for- 
ward and downward. By having the patient cross 
the arms upon the chest, the hands being placed 
upon the tips of the shoulders and then drawing the 
shoulders down and bending the head well down upon 
the chest, the greatest area of the posterior thorax 
is exposed to examination. Thus the supra-scapular 
and inter-scapular regions become artificially increased 
to the great convenience of the examiner. The above 
procedure is of value when the patient is standing or 
sitting up in bed. 

A position which gives the maximum of muscular 
relaxation and the greatest exposure of the upper lobes 
behind may be assumed by the patient while seated 
on a stool: the body is bent well forward, the head 
hanging downward and forward upon the chest, and 
the arms hanging down loosely outside the thighs. 

1 This very intensity of resonance may lead to error if the 
patient is examined while lying on a couch which is equipped 
with a box-spring. Ignorance of, or inattention to, the resonating 
cavity beneath the patient may cause confusion in interpreting 
the signs of percussion. 



CHAPTER III 
PERCUSSION IN DISEASE 

Enumeration of the signs of disease furnished by%percussion 
— Requirements for a practical knowledge of these signs — The 
distinctive characters of the morbid physical conditions repre- 
sented by, and the different diseases into the diagnosis of which 
enter the signs, severally, to wit: 1. Absence of resonance or 
flatness. 2. Diminished resonance. 3. Tympanitic resonance. 
4. Vesiculo-tympanitic resonance. 5. Amphoric resonance. 6. 
Cracked-metal resonance. 7. Unusual changes of tone — Sense 
of resistance felt in the practice of percussion as a morbid sign. 

Percussion in cases of disease furnishes signs 
which represent morbid physical conditions incident 
to the different pulmonary affections; with these 
physical conditions and their relations to pulmonary 
affections the student is supposed to be familiar (vide 
page 25 et seq.). 

The signs of disease furnished by percussion are 
resolvable into six, namely: 1. Absence of resonance 
or flatness. 2. Diminished resonance or dulness. 
3. Tympanitic resonance. 4. Vesiculo-tympanitic 
resonance. 5. Amphoric resonance. 6. Cracked-metal 
resonance. The two last named signs are properly 
varieties of tympanitic resonance, but it is most 
convenient to consider them as distinct signs. 

Knowledge of these six signs sufficient for their 
availability in physical diagnosis requires, first, a 



74 PERCUSSION IN DISEASE 

practical acquaintance with the characters which 
distinguish each from the others, as well as from 
the normal resonance; and second, a clear apprehen- 
sion of the significance of each, that is, the morbid 
physical conditions which they severally represent. 
Under these two aspects the signs will now be con- 
sidered. 

1. ABSENCE OF RESONANCE OR FLATNESS 

This sign is sufficiently defined by its name. It 
is absence of resonance or tone. Nothing is heard 
but a noise such as may be produced by percussing 
over a solid mass, for example, a limb composed of 
muscle and bone, or over a collection of liquid, for 
example, the abdomen in hydro-peritoneum or ascites. 
There being no resonance or tone, the sign has no 
characters pertaining to pitch or quality. It may be 
illustrated on the healthy chest by percussing in the 
right infra-mammary region below the line of hepatic 
flatness. 

There are four classes of morbid physical condi- 
tions giving rise to flatness on percussion — namely, 
(1) the presence of liquid either in the pleural sac 
or in pulmonary cavities; (2) liquid filling the air- 
vesicles; (3) complete solidification of lung; and (4) 
a tumor within the chest. 

Flatness on percussion always represents one of 
these morbid physical conditions. Extreme thicken- 
ing of the visceral and parietal pleura at the base of 
the lung may give a note so nearly flat that a differ- 



ABSENCE OF RESONANCE OR FLATNESS 75 

ential diagnosis cannot be made between thickened 
pleura and hydrothorax without the use of an exploring 
needle. 

These conditions are incident to different dis- 
eases, as follows: 

(1) Liquid in the pleural cavity is incident to 
pleurisy with effusion, empyema, and hydrothorax. 
A collection of pus constitutes pulmonary abscess, 
and phthisical cavities, or those caused by circum- 
scribed gangrene, may become filled with morbid 
liquid products. 

(2) Serous effusion into the air-vesicles consti- 
tutes pulmonary edema. Liquid blood extravasated 
characterizes hemorrhagic infarctus, pneumorrhagia, 
or pulmonary apoplexy. Pus infiltrating more or less 
of the parenchyma may be derived from an abscess 
either within the lung or elsewhere, for example, 
the liver, and from the pleural cavity in empyema 
when perforation of lung takes place. 

(3) Solidification of lung occurs in pneumonia 
from an exudation within the air-cells; it is produced 
by condensation from compression by liquid or air 
in the pleural sac, the pressure of a tumor, and by 
collapse; it exists in cases of phthisis, in interstitial 
pneumonia, and in neoplastic infiltration of lung. 

(4) Tumors within the chest are of different 
kinds, for example, aneurisms, primary and secondary 
neoplasms, and teratomata. In proportion to their 
size they occupy space belonging to the lung, as well 
as condensing the latter by pressure. Flatness may 
also be caused by the encroachment of organs situated 



76 PERCUSSION IN DISEASE 

below the diaphragm upon the thoracic space, as in 
cases of enlargement of the liver and spleen, and in 
massive ascites. 

Flatness on percussion in all these conditions is 
the same. The sign alone does not enable us to 
discriminate the conditions from each other, nor to 
determine the existing disease. 

Finding this sign present, the particular condition 
and the disease in each case are to be determined by 
the situation of the flatness, its extent, the associated 
physical signs furnished by auscultation, together 
with the other methods of exploration, and by the 
symptomatic phenomena. 

2. DIMINISHED RESONANCE OR DULNESS 

The resonance on percussion is diminished, or 
there is dulness, when the solids or liquids within 
the chest are morbidly increased without increase in 
the quantity of air, the increased amount of solids 
or liquids not being sufficient to cause flatness. Dimi- 
nution of air without increase of either solids or 
liquids, as in collapse of pulmonary lobules, also gives 
rise to dulness. We may formularize the physical 
conditions by saying, that they consist in an abnormal 
proportion of solids or liquids over the air in the 
pulmonary vesicles. 

Dulness varies in degree. It may be slight, mod- 
erate, considerable, or great. These adjectives of 
quantity express sufficiently the variations in this 
regard. The degree of dulness corresponds to the 



DIMINISHED RESONANCE OR DULNESS 77 

amount of the relative disproportion of solids or liquids 
over the air within the chest. 

The pitch of sound is higher than that of the normal 
resonance of the persons percussed. This is invariable; 
with dulness there is always more or less elevation 
of pitch. The quality is altered only in amount; there 
is, of course, less vesicular quality in proportion as 
the intensity of the resonance is diminished. 

The characters which distinguish this sign, thus, 
are, lessened intensity of resonance, elevation of pitch, 
and weakened vesicular quality. 

The morbid conditions giving rise to this sign are 
those which, existing in a greater degree, give rise 
to flatness. Morbid products within the pleural sac, 
fibrin, serum, pus, lymph, if not sufficient to cause flat- 
ness, give rise to dulness. The sign, therefore, occurs in 
pleurisy, empyema, and hydrothorax. The same is 
true of pulmonary edema, hemorrhagic infarctus, 
pneumorrhagia, and purulent infiltration of lung. 
Solidification of lung, w^hen not complete, occasions 
dulness; hence, it is a sign in pneumonia, vesicular 
and interstitial, in phthisis, in condensation of lung 
from compression, in collapse of pulmonary lobules, 
and in neoplastic infiltration. A tumor within the 
chest, not sufficiently large to cause flatness, gives 
rise to dulness. 

There are, however, some conditions giving rise to 
dulness, which are never sufficient to cause flatness. 
Pulmonary congestion limited to a lobe may diminish 
the resonance appreciably. The dulness may exist 
in the first stage of pneumonia, before solidification 



78 PERCUSSION IN DISEASE 

from pneumonic exudation has taken place. A layer 
of lymph upon the pleural surfaces causes dulness 
after the liquid effusion in pleurisy has been removed, 
and after the vesicular exudation in pneumonia is 
absorbed. Dulness may also be caused by a consider- 
able accumulation of mucus or coagulated blood 
within the intra-pulmonary bronchial tubes. 

The particular morbid condition which gives rise 
to dulness cannot be inferred from the characters of 
the sign: the sign only denotes that some one of the 
different morbid conditions exists. The condition 
which exists in each case, and the disease, are to be 
determined by the situation, extent, and degree of 
dulness, taken in connection with the information 
derived from other methods of exploration than per- 
cussion, together with the history and symptoms. 



3. TYMPANITIC RESONANCE 

Resonance is tympanitic whenever it is entirely 
devoid of the vesicular quality; in other words, any 
resonance which is non-vesicular is tympanitic. The 
leading distinctive character of the preceding sign 
(dulness) relates to intensity, whereas, the leading 
distinctive character of this sign relates to quality. 
Tympanitic resonance derives no distinctive char- 
acter from intensity; it may be either more or less 
intense than the resonance of health in the person 
percussed. This point is to be emphasized, inasmuch 
as with many the idea of tympanitic resonance involves 



TYMPANITIC RESONANCE 79 

increased intensity of sound; a resonance, be it ever 
so feeble, if it be non-vesicular, is tympanitic. If, 
however, the resonance be quite feeble, it is not always 
easy to determine whether there be, or be not, 
any appreciable vesicular quality. The term used 
by Stokes, namely, "tympanitic dulness," is prop- 
erly enough applied to a resonance with diminished 
intensity, in which a vesicular quality cannot be 
appreciated. As regards pitch, a tympanitic reson- 
ance is higher than the normal vesicular resonance. 
If there be any exceptions to this rule, they are ex- 
tremely infrequent. The tympanitic resonance over 
different parts of the abdomen is always higher in 
pitch than the resonance over healthy lung. 

The following are the morbid physical conditions 
which give rise to the tympanitic resonance: 

(1) Air in the pleural cavity. It is, therefore, a 
sign of pneumothorax. Frequently in this affection 
the tympanitic resonance is more intense than the 
resonance of health, the pitch being always more 
or less raised. 

(2) Pulmonary cavities containing air. It occurs, 
therefore, in cases of phthisis. In this disease the 
tympanitic resonance is limited to a circumscribed 
space corresponding to the site and size of the cavity, 
w T hereas, in pneumothorax, it frequently exists over 
a considerable part, or the whole, of the affected side 
of the chest. 

(3) Complete solidification of the whole or a part 
of the upper lobe of lung. The tympanitic reson- 
ance under these circumstances must be derived 



80 PERCUSSION IN DISEASE 

from the air in the lower part of the trachea and the 
bronchial tubes exterior to the lungs. This is the 
explanation of the sign in the second stage of pneu- 
monia affecting an upper lobe, and in certain cases 
of phthisis prior to the stage of excavation. Dilata- 
tion of the intra-pulmonary bronchial tubes, with 
solidification surrounding them, as in some cases of 
interstitial pneumonia or cirrhosis of lung, may give 
rise to tympanitic resonance. 

(4) Conduction of resonance from the stomach or 
colon containing air or gas. A gastric tympanitic 
resonance is frequently conducted over a part, and 
sometimes over the whole, of the left side of the chest. 
This is more likely to occur when the left lung is 
solidified. On the right side less frequently a tym- 
panitic resonance may be conducted upward from the 
colon to a greater or less extent. 

Tympanitic resonance may be illustrated by per- 
cussion over the hollow abdominal viscera of the 
abdomen, provided they contain air or gas. The 
sign may be imitated by percussing an inflated bladder 
or India-rubber balls. The pitch will be found to 
vary according to the size and the degree of inflation 
of the bladder or balls. To illustrate this resonance 
in proximity to a vesicular resonance produced arti- 
ficially, one-half of the soft portion of an oblong loaf 
of bread may be removed, leaving intact the upper 
crust. Percussion over this half of the loaf illustrates 
the tympanitic, and over the other half the vesicular, 
resonance. 



VESICULO-TYMPANITIC RESONANCE 81 

4. VESICULO-TYMPANITIC RESONANCE 

This name was proposed by the author many 
years ago to denote a sign with the following dis- 
tinctive characters: The resonance increased in 
intensity; the quality a combination of the vesicular 
with a tympanitic, and the pitch high in proportion as 
the tympanitic quality predominates over the vesicular. 

The sign represents especially one morbid phy- 
sical condition, namely, an abnormal accumulation 
of air in consequence of dilatation of the air-vesicles, 
that is, pulmonary or vesicular emphysema. The 
sign also is present in interstitial or interlobular em- 
physema. The relation of the sign to these affections 
renders it of great value in physical diagnosis. 

A vesiculotympanitic resonance is obtained when 
the pleural sac is partially filled with liquid, by per- 
cussing over the lung on the affected side. Although 
the pressure of the liquid diminishes the volume of 
the lung, as a rule, it yields this sign. The resonance 
is vesiculo-tympanitic above the liquid when the 
latter is sufficient to fill a third, a half, or even two- 
thirds of the intra-thoracic space. The sign is also 
obtained over the upper lobe when the lower lobe 
is solidified in the second stage of pneumonia, and 
over the lower lobe when the upper lobe is solidified. 1 

1 The explanation given above for the mechanism or cause of 
vesiculo-tympanitic resonance does not at present meet with 
approval. It is altogether probable that it is not the abnormal 
accumulation of air, but the altered resilience, or diminished 
elastic tension of the pulmonary tissue which is responsible 
for the altered note. — Ed. 
6 



82 PERCUSSION IN DISEASE 

A loaf of bread may be used to illustrate a vesiculo- 
tympanitic resonance, as follows: By means of 
a hollow cylinder remove longitudinal sections in 
one-half of the loaf, leaving the crust intact. The 
spaces thus produced yield a tympanitic resonance, 
and the portions which surround these spaces give 
the vesicular resonance. The vesicular and the tym- 
panitic quality are thus combined, with elevation of 
pitch and increased intensity; over the other half of 
the loaf the resonance is purely vesicular. Another 
method of illustrating this sign out of the body is 
to inflate the human lungs, or the lungs of the sheep 
or calf, considerably beyond the limit of a normal 
inspiration. Inflated beyond that limit the emphy- 
sematous condition is produced, and the resonance 
represents that condition. 

5. AMPHORIC RESONANCE 

Resonance is said to be amphoric when it has a 
musical intonation analogous to that produced by 
blowing over the mouth of an empty bottle. An 
amphoric sound is easily illustrated by filliping the 
cheek made tense, the mouth not completely closed, 
and the jaws separated, as is done when the sound 
of a liquid flowing from a bottle is imitated. By 
varying the size of the cavity of the mouth the 
amphoric sound thus produced may be made to 
vary much in pitch. This illustration exemplifies 
the mechanism of the sign in disease. 

The sign represents a pulmonary cavity which is 



AMPHORIC RESONANCE 83 

generally phthisical. The conditions, aside from 
the existence of the cavity, are, rigidity of its walls, 
so that they do not collapse, the presence, of course, 
of air within the cavity, and free communications 
with the bronchial tubes. These accessory condi- 
tions are not constant, so that an amphoric resonance 
over a cavity is sometimes found, and at other times 
is wanting. Directly after having been wanting, it 
may be reproduced if the patient expectorate freely. 

When percussion is made with reference to this 
sign,, the mouth of the patient should be open, and 
one or two rather forcible blows are better than a 
series of four or six. The amphoric sound may be 
often distinctly perceived if the ear be brought into 
close proximity to the patient's open mouth, when 
the sign is not appreciable otherwise. It may be 
rendered still more distinct by means of the binaural 
stethoscope, the pectoral extremity being close to 
the mouth of the patient. 

As a cavernous sign the amphoric resonance is 
very reliable; but it does not invariably denote a 
pulmonary cavity. It is obtained in some cases of 
pneumothorax, the pleural space filled with air form- 
ing a cavity, which communicates with the bronchial 
tubes through a perforation of the lung situated above 
the level of the liquid. It is sometimes obtained over 
a solidified portion of lung situated in close proximity 
to a primary bronchus, the resonance being derived 
from the air within the latter. It is occasionally 
produced by percussing over the site of the primary 
bronchus in the second stage of pneumonia affecting 



84 PERCUSSION IN DISEASE 

an upper lobe. In children, owing to the yielding 
of the costal cartilages, it may even be produced in 
health over a primary bronchus. In all these excep- 
tional instances the associated signs and symptoms 
will prevent the error of attributing the sign to a 
pulmonary cavity. 

This sign is properly a variety of tympanitic reson- 
ance. 

6. CRACKED-METAL RESONANCE 

The name of this sign, expressing an analogy to 
the sound produced by striking a cracked metallic 
vessel, denotes its peculiar character. It may be 
imitated by folding the hands so as to form a cavity 
and striking them upon the knee, in the familiar trick 
of producing in this way a sound as if metal coins 
were betweem the palms. This illustration, also, 
exemplifies the mechanism of the sign. Like the sign 
last described, it is a variety of tympanitic resonance. 

The cracked-metal, like the amphoric, resonance 
represents generally a phthisical cavity. Percussion 
is to be made in the same way as for the production 
of the amphoric resonance, and, like the latter, the 
cracked-metal character is often perceived if the ear, 
or, better still, the stethoscope be brought close to the 
patient's mouth when otherwise it is not appreciable. 

The cracked-metal and the amphoric resonance 
are often associated; and the statements made with 
respect to the exceptional instances in which the 
latter is produced, without the existence of a pul- 
monary cavity, will apply equally to the former. 



WINTRICH AND GERHARDT PHENOMENA 85 

7. THE WINTRICH, WILLIAMS, AND GERHARDT 
PHENOMENA 

If a patient who exhibits a vesiculotympanitic 
note or tympany over a cavity opens his mouth 
during percussion the pitch of the note is raised. 
This is called Wintrich's tone change or Wintrich's 
phenomenon. When this phenomenon occurs where 
there is infiltrated or contracted lung tissue but no 
cavity it is called Williams' tracheal tone. If the 
pitch of a tympanitic note over a cavity changes with 
the patient's position we speak of this change as Ger- 
hardt's tone change or phenomenon. It indicates a 
change of the shape of the resonating chamber, owing 
to the shifting of fluid on change of position. 

In addition to the acoustic phenomena produced 
by percussion with the fingers applied to the chest 
instead of a pleximeter, an abnormal sense of resist- 
ance is felt in certain conditions of disease. In health, 
with a somewhat forcible percussion, the walls of the 
chest are felt to yield in proportion as the costal 
cartilages are flexible. This yielding is diminished 
or ceases when a collection of liquid in the pleural 
cavity, or liquid in the air-vesicles, and solidification 
of lung, offer a mechanical obstacle thereto. An 
abnormal sense of resistance on percussion, thus 
determinable by comparison of the two sides of the 
chest, is a sign representing some one of the morbid 
physical conditions just named. This properly belongs 
among the signs obtained by palpation. The sign is 
to be taken in connection with other signs in deter- 
mining the condition which exists in particular cases. 



CHAPTER IV 
AUSCULTATION IN HEALTH 

Importance of the study of the auscultatory sounds in health — 
Immediate and mediate auscultation — Advantages of the 
binaural stethoscope — Rules to be observed in auscultation — 
Divisions of the study of auscultation in health — The normal 
laryngeal and tracheal respiration — The normal vesicular 
murmur; its distinctive characters, and the variations in the 
different regions on the same side, and in corresponding regions 
on the two sides of the chest — The normal vocal resonance — 
The laryngeal and tracheal voice and whisper — The normal 
thoracic vocal resonance and fremitus; the distinctive characters 
of each: the variations in different regions on the same side, and 
in corresponding regions on the two sides of the chest — The 
normal bronchial whisper, with its variations in different regions 
on the same side, and in corresponding regions on the two sides 
of the chest. 

The term auscultation, limited in its application 
to the respiratory system, denotes the act of listen- 
ing to the normal and abnormal sounds produced 
by respiration, voice, and cough. In this and the 
next chapter, the method of exploration thus named 
will be considered in its application to the respira- 
tory system; it will be considered subsequently as 
applied to sounds relating to the circulatory system. 

The study of auscultatory sounds in health is 
essential as preparatory for the study of ausculta- 
tion in disease. The student must be familiar with 



AUSCULTATION IN HEALTH 87 

the normal sounds before undertaking to become 
acquainted with those which represent morbid con- 
ditions. Ample time and attention should be given 
to the study of auscultation in health. The omis- 
sion to do this is a frequent cause of difficulty and 
want of success in attaining to a satisfactory pro- 
ficiency in physical diagnosis. The practical skill 
required in diagnosis may be obtained in advance by 
devoting sufficient study to the healthy chest before 
entering on the study of the auscultatory signs of 
disease. Moreover, as will be seen, some of the most 
important of the morbid signs have their analogues 
in certain normal sounds pertaining to the respiratory 
system. 

Auscultation is either immediate or mediate. It 
is immediate when the ear is applied directly to the 
chest, which may be either denuded or covered with 
a cloth or more or less of the clothing. It is mediate 
when the sounds are conducted to the ear by means 
of an instrument called a stethoscope. The student 
should practise both immediate and mediate auscul- 
tation. The direct application of the ear to the chest 
suffices for diagnosis in many cases of disease; but 
there are sometimes objections to this by the patient 
on the score of delicacy, and by the auscultator on 
the score of the uncleanliness of the person examined. 
There are certain parts of the chest which can only 
be explored by the stethoscope, and this instrument 
has the advantage of circumscribing the space whence 
the auscultatory sounds are derived. Moreover, by 
means of the stethoscope, which is to be preferred over 



88 AUSCULTATION IN HEALTH 

the great variety of instruments heretofore in use, 
the sounds are heard much better than by immediate 
auscultation. 

Stethoscope. — The stethoscope which is to be preferred 
conducts the sounds into both ears, that is, it is binaural. 
In this consists its great superiority. An instrument 
must be very good, or it is without value. The knobs 
which are to enter the ears must be of the right size; 
if they enter too far they occasion pain. The curves 
at the aural extremity must be such that the aperture 
is in the direction of the meatus of the ear. The 
flexible tubes must not be stiff, and their movements 
must be noiseless. All the tubes must be unobstructed, 
for it is the air within the tubes which chiefly conducts 
the sounds. In the use of the instrument it should be 
applied to the chest without any intervening clothing. 

The use of the binaural stethoscope is so universal 
and the types are, on the whole, so similar that it seems 
out of place in the present edition to discuss the matter 
in detail. The selection of the chest-piece, whether 
large or small, funnel or bell-shaped, is a matter for 
the individual physician to decide according to his 
need and use. The flat chest-piece used in the Bowles' 
phonendoscope is convenient in examining the posterior 
regions of the chest, in patients so ill in bed that the 
chest cannot be made easily accessible in all its 
parts. 1 

1 The makes of stethoscopes provided by Tiemann and Ford, 
in New York, and the Gannett model used largely in Boston 
and Baltimore, are reliable. The Bowies' phonendoscope is 
made by Pilling & Sons, of Philadelphia. 



RULES FOR AUSCULTATION 89 

Rules for Auscultation. — The rules to be observed in 
the practice of auscultation, in health and disease, may 
be here introduced. 

In auscultation, as in percussion, corresponding 
situations on the two sides of the chest are to be 
explored successively, and compared. When the 
stethoscope is used, the pectoral extremity must be 
applied on each side with the same degree of pressure; 
this is especially essential in the comparison of 
vocal sounds. In immediate auscultation, the ear 
is to be applied with a certain degree of force, and 
a thin layer of clothing does not interfere materially 
with the perception of auscultatory sounds. The ear 
not applied to the chest may or may not be closed 
by the finger in listening to the respiratory sounds; 
it should be closed in listening to the vocal sounds, 
in order to prevent confusion from attention to the 
voice from the patient's mouth. In immediate auscul- 
tation, whenever practised, the auscultator should 
take a position which will not interfere with the sense 
of hearing, and not occasion a feeling of discomfort. 
These difficulties are in the way of auscultating with 
the body bent forward; the sense of hearing is dulled 
by the detention of blood in the head, and the position 
cannot be maintained without discomfort. The 
person examined, if practicable, should be sitting, and 
the position for the auscultator is that of kneeling 
on one knee, and lowering, if necessary, the body, 
so that the head may be kept upright. These points 
are less important if the binaural stethoscope be used. 

When listening to respiratory sounds, it is gener- 



90 AUSCULTATION IN HEALTH 

ally desirable that the person examined should breathe 
with somewhat greater force than in ordinary breath- 
ing; but it is important that the normal rhythm of 
respiration should be unchanged. Persons when 
requested to breathe with increased force are apt to 
err in breathing violently, and sometimes too slowly. 
The readiest mode of obtaining what is desired, is 
for the examiner to illustrate it by his own breath- 
ing. A complete expiration is important in order to 
secure a satisfactory inspiration. It should, therefore, 
be made clear by explanation and illustration, that 
each expiration should be finished before the follow- 
ing inspiration. 

The ability to abstract the mind from thoughts 
and other sounds than those to which the attention 
is to be directed, is essential to success in ausculta- 
tion. All persons do not possess equally this ability, 
and herein is an explanation in part of the fact that 
all are not alike successful. To develop and cultivate 
by practice the power of concentration is an object 
which the student should keep in view. Generally, 
at first, complete stillness in the room is indispensable 
for the study of auscultatory sounds; with practice, 
however, in concentrating the attention, this becomes 
less and less essential. 

The study of auscultation in health embraces the 
following : 

1. The sounds produced by respiration as heard 
over the larynx and trachea, or the normal laryngeal 
and tracheal respiration. 



LARYNGEAL AND TRACHEAL RESPIRATION 91 

2. The sounds heard over the chest in the acts 
of respiration. These sounds, coming chiefly from 
the air-vesicles, constitute what is called the normal 
vesicular murmur. 

3. The resonance heard over the chest, and the 
vibration or thrill produced by the loud voice, or 
the normal vocal resonance and fremitus. 

4. The sounds heard over the chest with the whis- 
pered voice, or, inasmuch as these sounds are conducted 
chiefly by the air in the bronchial tubes, the normal 
bronchial whisper. 

These four normal signs will be considered in the 
foregoing order. 



NORMAL LARYNGEAL AND TRACHEAL 
RESPIRATION 

For all practical purposes the laryngeal and the 
tracheal respiration may be considered to be iden- 
tical, that is, the shades of difference between the 
sounds in these two situations are not of importance 
as regards the application to physical diagnosis. The 
laryngeal respiration is more readily studied than the 
tracheal, and for the study of each the stethoscope is 
necessary. 

Applying the stethoscope over the side of the larynx, 
the person examined breathing with some increase 
of force, but without any alteration in rhythm, a 
sound is heard with each of the two acts of respiration. 
The inspiratory and the expiratory sound, studied 



92 AUSCULTATION IN HEALTH 

separately and contrasted with each other, have 
the following characters relating to intensity, pitch, 
quality, duration, and rhythm: The inspiratory 
sound is of variable intensity. In ordinary breathing 
it varies much in different persons, and in different 
acts of breathing in the same person. It is alwaj^s 
intensified in forced breathing. The pitch is high 
when compared with the inspiratory sound as heard 
over the chest. The quality of the sound is well 
defined by the word tubular; the sound at once sug- 
gests a current of air through a tube. The duration 
of the sound is from the beginning to nearly, not 
quite, the end of the inspiratory act. The characters of 
the inspiratory sound, thus, are more or less intensity, 
a high pitch, a tubular quality, and a duration a little 
less than that of the act of inspiration. 

An expiratory sound is always heard with forced 
breathing. As regards duration, it is as long as, or 
longer than, the sound of inspiration. In general it 
is more intense than the sound of inspiration. The 
pitch is higher than that of the inspiratory sound. 
The quality is the same as that of the inspiratory 
sound, namely, tubular. 

Repeating the characters distinctive of the normal 
laryngeal respiration, they are as follows: The in- 
spiratory sound is of variable intensity, high in pitch, 
and tubular in quality. The expiratory sound is as 
long as, or longer than, the inspiratory sound; it 
is higher in pitch, and usually more intense. Owing 
to the inspiratory sound not continuing quite to the 
end of the inspiratory act, there is a very short interval 



NORMAL VESICULAR MURMUR 93 

between the two sounds. In this latter point consists 
the only variation between the rhythm of the acts of 
breathing and that of the sounds. 

The foregoing characters should not only be verified 
by the student, but he should become so familiar 
with them by practice that it requires no effort of the 
mind to recollect them. It will be seen hereafter that 
these characters of the normal laryngeal respiration 
are precisely those which distinguish an important 
morbid physical sign, namely, the bronchial or tubular 
respiration. 

NORMAL VESICULAR MURMUR 

This is the name usually given to the respiratory 
sounds heard over the different regions to the chest. 
These sounds should be studied with the ear applied 
directly to the chest (immediate auscultation), as 
well as with the stethoscope. In commencing the 
study, the middle of the anterior surface of the chest 
on the right side, to avoid the sounds of the heart, 
or, still better, the posterior aspect below the scapula 
on either side should be selected. The person examined 
should breathe somewhat more forcibly than in ordin- 
ary breathing, but not violently nor quickly, nor too 
slowly, the normal rhythm being unchanged. Chil- 
dren are better than adults for this study, owing 
to the greater intensity of the murmur in early life. 

The characters which belong to the inspiratory 
and the expiratory sound in the normal vesicular 
murmur are as follows: The inspiratory sound is of 



94 AUSCULTATION IN HEALTH 

variable intensity. There is a wide variation in dif- 
ferent healthy persons. In some persons it is so 
feeble as scarcely to be appreciable even with the 
binaural stethoscope. The pitch of the sounds, com- 
pared with the inspiratory sound in the normal laryn- 
geal or tracheal respiration, is notably low. The 
quality of the sound is peculiar; no distinct idea of 
the quality can be formed by any comparison. The 
name used to designate the quality is vesicular, this 
name only denoting that the air-vesicles are in some 
way concerned in the production of the sound. This 
vesicular quality must be impressed upon the percep- 
tion and memory by direct observation. The duration 
of the inspiratory sound is from the beginning to the 
end of the inspiratory act. 

An expiratory sound is not always, although gener- 
ally, appreciable. It is much less intense than the 
sound of inspiration. It is notably lower in pitch 
than the sound of inspiration. The quality of the 
sound is neither vesicular nor tubular. It may be 
called simply a blowing sound, and may be imitated 
by blowing with the mouth partially opened. The 
duration is much shorter than that of the inspiratory 
sound. 

The characters, thus, which distinguish the normal 
vesicular murmur are, an inspiratory sound variable 
in intensity, low in pitch, and vesicular in quality; 
an expiratory sound less intense than the inspira- 
tory, still lower in pitch, non-vesicular and non- 
tubular, or simply blowing; the inspiratory sound 
continuing from the beginning to the end of the 



NORMAL VESICULAR MURMUR 95 

inspiratory act, and the expiratory sound beginning 
with the expiratory act but ending before this act is 
completed, its duration, relatively to the inspiratory 
sound, being variable, but averaging about a fifth. 
The inspiratory sound continuing to the end of inspira- 
tion, and the expiratory sound beginning with the 
act of expiration, it follows that there is no interval 
between the two sounds. It is to be remarked that 
an interval is not infrequently produced by the per- 
son examined holding the breath after inspiration 
is completed. This variation in the rhythm of the 
acts, of course, produces a corresponding variation in 
sounds of breathing. 

The characters of the normal vesicular respiration 
may be studied by inflating the lungs removed from 
the human cadaver, or from the sheep or calf, and 
applying the binaural stethoscope directly upon the 
pulmonary surface. In this experiment the vesic- 
ular quality is strongly marked. In the same way 
the tracheal respiration may be studied and its charac- 
ters contrasted with those of the vesicular respiration. 
It is recommended to the student to resort to this 
readily available method to study the normal respira- 
tory signs. 

Having become familiar with the characters of 
the normal vesicular respiration as compared with 
those of the normal laryngeal or tracheal respiration, 
the student may then proceed to study the former 
in the different regions of the chest. The murmur 
will be found to present variations in the different 
regions on the same side, and in the corresponding 



96 AUSCULTATION IN HEALTH 

regions on the two sides of the chest. The variations, 
within the range of health, in the latter are especially 
important. The following account of the murmur 
in the different regions embodies the results of the 
analysis of a series of recorded examinations of healthy 
persons. 1 

Right and Left Infra-clavicular Region. — The mur- 
mur in this region, on either side, differs more or 
less from the murmur as heard in the anterior regions 
below, or in the infra-scapular region. The vesicular 
quality in the inspiration is less marked. The pitch 
is higher. The expiratory sound is longer, less feeble, 
and higher in pitch. The difference between the two 
sides in this region is especially important with refer- 
ence to diagnosis. The intensity of the inspiratory 
sound is almost invariably greater on the left side. 
Its vesicular quality is more marked, and the pitch 
is lower. Per contra, the inspiratory sound on the 
right side, in this region, is less intense, less vesicular, 
and higher in pitch than the inspiratory sound on the 
left side. In forced breathing the intensity of the 
murmur is increased more on the left than on the right 
side. The expiratory sound is sometimes wanting 
on the left, when it is heard on the right side. On the 
right side, the expiratory sound is longer than on 
the left side. It may be prolonged on the right side 
to nearly or quite the length of the inspiratory sound. 
Sometimes on the right side the pitch of the expira- 
tory is higher than that of the inspiratory sound on the 

1 Vide Prize Essay, Trans. Amer. Med. Assoc, 1852, vol. v. 



NORMAL VESICULAR MURMUR 97 

same side, and it may have a tubular quality. A rare 
peculiarity is a prolonged, high, tubular expiratory 
sound on both sides, analogous to the laryngeal or 
tracheal expiration. When this is the case, the pitch 
of the expiratory sound is higher on the left than on 
the right side 

The most reasonable as well as the most recent 
explanation for the differences in the respiratory 
sounds in the right and left infra-clavicular regions, 
and an explanation which seems to be based on the 
best understanding of the problem, is one given by 
Fetterolf. 1 He ascribes the difference in intensity and 
character of the sounds on the right side to the fact 
that the trachea is throughout practically its entire 
thoracic course in contact with the right upper lobe, 
while it is separated from the left lung by 3 cm. or 
more of large bloodvessels, and esophagus with areolar 
and lymphatic tissue. It is this intimate relation 
with the trachea which seems to account for the 
greater length of the expiratory sound on the right 
side as well as for the other characteristic differences. 

These several modifications of the respiratory 
murmur in the infra-clavicular region are marked 
in proportion as the sounds are studied near the 
sternum, that is, over the site of the primary bronchi. 
The respiratory murmur in this situation has been 
called the normal bronchial respiration, from its 
resemblance to the morbid sign so named. It may 
be more properly called a vesiculo-tubular, or the 

1 Arch. Int. Med., 1909, iii, No. 1. 



98 AUSCULTATION IN HEALTH 

normal broncho-vesicular respiration, the characters 
being those of the morbid sign which, under the latter 
name, will be described in the next chapter. 

In the diagnosis of diseases, especially of phthisis, 
due allowance must be made for the points of dis- 
parity which exist normally between the two sides 
of the chest in the infra-clavicular region. Without 
a practical knowledge of these points of disparity 
error in diagnosis can hardly be avoided. 

Right and Left Scapular Region. — As compared 
with the infra-clavicular region, the respiratory 
murmur heard over the scapula on either side is 
feeble, and the vesicular quality is less marked. The 
inspiratory sound is generally weaker and the pitch 
higher on the right than on the left side. The expira- 
tory sound is more constantly heard on the right 
than on the left side. It may be prolonged on the 
right side, and is sometimes higher in pitch than the 
inspiratory sound. Compared with the left side, 
the murmur on the right, in this region, thus may 
have vesiculo-tubular or broncho-vesicular characters 
more or less marked. 

Right and Left Inter-scapular Region. — In the upper 
and middle portions of this region, the normal char- 
acters are the same as in the sterno-clavicular portion 
of the infra-clavicular region. The same points of 
disparity between the two sides are more or less 
marked here as they are anteriorly over the site of 
the primary bronchi. 

Right and Left Infra-scapular Region. — The inten- 
sity of the murmur is greater than over the scapular 



NORMAL VOCAL RESONANCE 99 

region. In most persons there is no notable disparity 
between the two sides; when a disparity exists, the 
intensity is greater and the pitch lower on the left 
side. A prolonged, high-pitched, bronchial expira- 
tory sound is sometimes transmitted below the scapula 
on the right side. 

Right and Left Mammary and Infra-mammary Regions. 
— The inspiratory sound in these regions is less intense 
than in the infra-clavicular region; the vesicular 
quality is more marked, and the pitch is lower. An 
expiratory sound is often wanting. 

Right and Left Axillary and Infra-axillary Regions. — 
The inspiratory sound in these regions is as intense 
as in any portion of the chest. The intensity is less 
in the infra-axillary than in the axillary region, and 
the pitch is lower. In some persons the murmur 
on the two sides presents no disparity, but in other 
persons the vesicular quality is somewhat more marked 
and the pitch is lower on the left than on the right 
side. An expiratory sound is oftener heard than in 
the mammary and infra-mammary regions. 

NORMAL VOCAL RESONANCE 

Laryngeal and Tracheal Voice. — It will prepare the 
student for the appreciation of the distinctive char- 
acters of the morbid signs pertaining to the voice 
to study the vocal signs over the larynx and trachea, 
Applying the stethoscope either over the broad sur- 
face of the thyroid cartilage, or just above the sternal 
notch, and requesting the person examined to count 



100 AUSCULTATION IN HEALTH 

with a moderate intensity of voice, the auscultator 
perceives a strong resonance, with a sensation of 
concussion or shock, and a sense of vibration, thrill, 
or fremitus. The voice seems to be concentrated 
and near the ear. Sometimes the articulated words 
are transmitted so as to be heard more or less dis- 
tinctly. The laryngeal or tracheal voice (laryngophony, 
tracheophony) thus embraces different elements, 
namely, 1st, the vocal resonance; 2d, the concen- 
tration and nearness to the ear; 3d, the vibration, 
thrill, or fremitus; and 4th, the transmission of the 
speech, the latter corresponding to pectoriloquy. 
These different elements will be found to enter into 
the distinctive characters of morbid vocal signs. 

The sounds heard over the larynx and trachea 
when words are spoken in a whisper should be studied, 
inasmuch as important morbid signs relate to the 
w T hispered voice. Whispered words occasion little 
or no shock or thrill, but an intense, high-pitched 
tubular sound, with a sensation as if a current of air 
were directed into the ear through the stethoscope. 
This sound corresponds to the sound of expiration 
in laryngeal or tracheal respiration; the two sounds 
are, in fact, identical if, as is the case with some excep- 
tions, the person whisper with the expiratory breath. 
Articulated words are transmitted with more or less 
distinctness, thus corresponding with the morbid 
sign called whispering pectoriloquy. 

Normal Thoracic Vocal Resonance and Fremitus. — 
The vocal resonance over the chest is to be studied 
both by means of the stethoscope and by immediate 



NORMAL VOCAL RESONANCE 101 

auscultation. When the latter is employed the ear 
not applied to the chest should be closed in order 
to exclude the entrance of sound from the mouth of 
the person examined. When the stethoscope is em- 
ployed, care must be taken, in making a comparison 
between the two sides of the chest, or between dif- 
ferent regions on the same side, that the pectoral 
extremity of the instrument be pressed with an equal 
amount of force against the chest. The intensity 
with which the vocal resonance is transmitted is much 
affected by the degree of pressure with the stethoscope. 

The situations in which the student should com- 
mence the study of the normal vocal resonance are 
those selected for beginning the study of the normal 
vesicular murmur, namely, the middle of the anterior 
aspect of the chest on the right side, and below the 
scapula behind. 

With the stethoscope or the ear directly applied 
in the situations just named, the person examined 
should be requested to count one, two, three, in a 
uniform tone and with moderate force. The ex- 
aminer should himself pronounce these numerals, 
in order to show the manner of counting. This is 
far better than asking a question and studying the 
resonance during the answer of the person examined. 
The objection to the latter mode is, the attention of 
the examiner is divided between the characters of 
the thoracic resonance and the idea conveyed by 
the answer. The characters of the vocal resonance 
in these situations are as follows. 

The voice is heard with an intensity which varies 



102 AUSCULTATION IN HEALTH 

very much in different persons; in some the reson- 
ance is feeble, and it may be almost inappreciable, 
while in others it is quite intense. The intensity 
depends greatly on the loudness and lowness in pitch 
of the voice of the person examined. The resonance 
is notably weaker in women than in men. It is rarely 
attended w T ith a sense of concussion or shock. It is 
diffused; that is, it does not seem to be concentrated 
like the tracheal or laryngeal vocal resonance. It 
evidently comes from a certain distance; that is, 
the sound does not seem to be near the ear. Impres- 
sion of the distance of the sound is highly distinctive 
of the normal resonance as compared with a morbid 
vocal sign (bronchophony). The resonance is accom- 
panied by a sense of vibration, thrill, or fremitus, the 
intensity of which, like the resonance, varies much 
in different persons. This fremitus is properly not 
an acoustic but a tactile sign. The normal vocal 
fremitus, together with its abnormal modifications, 
belong to the method of physical exploration called 
palpation. It is, however, appreciated by the ear as 
well as by the touch, and may be studied in the prac- 
tice of auscultation. The student should practically 
distinguish from each other, and study separately, 
the vocal resonance and vocal fremitus. 

From the foregoing characters the normal vocal 
resonance may be defined as diffused, distant, vari- 
able in intensity, and accompanied with more or less 
vibration, thrill, or fremitus. 

Having become practically familiar with these 
characters of the normal vocal resonance in the situ- 



NORMAL VOCAL RESONANCE 103 

ations in which they are first to be studied, the 
next object of study relates to the normal variations 
in the different regions on the same side of the chest, 
and in corresponding regions on the two sides. In 
giving an account of these variations, based on a 
series of recorded examinations in healthy persons, 
the different regions will be considered in the same 
order as in the study of the variations of the 
respiratory sounds (vide p. 96 et seq.). 

Infra-clavicular Region. — The vocal resonance in 
this region on either side is more intense than in 
the anterior regions below, the intensity, however, 
in different persons being very variable. Irrespec- 
tive of intensity, it is less diffused nearer the ear, 
and the pitch is somewhat higher. These latter 
variations are marked chiefly in the sterno-clavic- 
ular extremity of the region, that is, over the site of 
the primary bronchi. In some persons the concen- 
tration, nearness to the ear, and elevation of pitch, 
especially on the right side, are such as to approxi- 
mate the normal resonance to the morbid sign called 
bronchophony. The characters of this sign will be 
considered in the next chapter, but it is important 
to know that exceptionally these characters may be, 
in a measure, illustrated in health in the infra-clavic- 
ular region. The resonance may then be termed 
normal bronchophony. 

A comparison of the resonance in the region on 
the right side and on the left side always shows a 
disparity. The resonance on the right side is invari- 
ably greater. The degree of difference between the 



104 AUSCULTATION IN HEALTH 

two sides varies in different persons. The resonance 
may be more or less marked on the right and nearly 
wanting on the left side. Allowance is to be made 
for the points of normal disparity between the two 
sides in the diagnosis of disease; hence, the student 
must become practically familiar with them. 1 

The vocal vibration or fremitus varies fully as 
much as the vocal resonance in different persons. 
Its intensity is not always proportionate to that of 
the resonance; that is, the resonance may be com- 
paratively weak when the fremitus is strong, and 
vice versa. The fremitus, like the resonance, is always 
greater on the right than on the left side, the dis- 
parity, like that of the resonance, varying considerably 
in different persons. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular region. 
It is also more diffused and distant. The intensity 
is always greater on the right side. These state- 
ments are alike applicable to the vocal fremitus. 

Inter-scapular Region. — The intensity of the reson- 
ance here is nearly or quite as great as in the sterno- 
clavicular extremity of the infra-clavicular region. 
The resonance has in some persons in this region the 
characters of bronchophony. The intensity is always 
greater on the right side. The fremitus is more or 
less marked, and always more marked on the right 
than on the left side. 



1 For explanation, v. s., Fetterolf, Arch. Int. Med., 1909, iii, 
No. 1. 



NORMAL BRONCHIAL WHISPER 105 

Infra-scapular Region. — As a rule, the resonance 
in this region is stronger than over the scapula. It 
is always characterized by diffusion and distance. 
As in all the regions, it varies much in different per- 
sons, and is stronger on the right than on the left 
side. These statements are also applicable to fremitus. 

Mammary and Infra-mammary Regions. — The reson- 
ance is notably less than at the summit of the chest. 
The characters of bronchophony are never present. 
The intensity is greater on the right side. The same 
is true of fremitus. 

Axillary and Infra-axillary Regions. — The resonance 
in these regions, and especially in the axillary region, 
is greater than over the mammary and infra-mam- 
mary regions. It is, of course, stronger on the right 
side. The characters as contrasted with those of 
bronchophony, namely, distance and diffusion, are 
marked. Fremitus is more or less marked, and, of 
course, more marked on the right than on the left 
side. 

NORMAL BRONCHIAL WHISPER 

Prior to the publication of the author's work on 
the Physical Exploration of the Chest, in 1856, signs 
in health and disease relating to the whispered voice 
had received but little attention. In that work, 
and more fully in the second edition, published in 
1866, a series of signs accompanying whispered words 
were described and named. As a point of departure 
for the study of the morbid signs thus obtained, of 



106 AUSCULTATION IN HEALTH 

course the signs in health must first be studied. The 
sounds which are heard over different parts of the 
chest in health I have embraced under the name, 
the normal bronchial whisper. The pertinency of 
this name is derived from the fact that the conduction 
of the sound produced by the whispered voice must 
be chiefly by the air contained in the bronchial tubes. 
The sound heard over the trachea and larynx may be 
distinguished as the laryngeal or tracheal whisper, 
the characters of which have been already stated 
(vide p. 100). 

It will facilitate the study of the normal bronchial 
whisper, as well as of the morbid signs, to consider 
that the characters of the sounds produced with the 
whispered voice are identical with those produced 
by the act of expiration, in all respects save intensity. 
Whispered words are produced, as a rule, by an act 
of expiration, the sounds being more intense gen- 
erally than those which accompany even forced breath- 
ing. Curiously enough, there are exceptions to this 
rule. Some persons insist upon whispering wdth the 
act of inspiration, and there are some persons who have 
never acquired the ability to w T hisper. It will be at 
once evident that the pitch and quality of sounds, 
produced by whispered words with the act of 
expiration, must be the same as those of the sounds 
of expiration in breathing. 

Selecting for the study of the normal bronchial 
whisper the same situations as in commencing the 
study of the normal respiratory murmur, and the 
normal vocal resonance — namely, the middle of the 



NORMAL BRONCHIAL WHISPER 107 

chest in front, on the right side, and the infra-scapular 
region behind, with the whispered voice in these 
situations is heard, in most persons, a feeble, low- 
pitched blowing sound, these characters corresponding 
to those of the expiratory sound in forced breathing. 
The normal bronchial whisper in these situations is 
not in all persons appreciable. 

In the infra-clavicular region, the bronchial whisper 
is heard, with variable intensity, in most persons. It 
is somewhat higher in pitch than the whisper below 
this region. It is louder and higher in the sterno- 
clavicular than in the acromial extremity. In the 
former situation it has not infrequently a tubular 
quality. It is louder on the right than on the left 
side of the chest. It is sometimes heard on the right 
when it is inappreciable on the left side. When heard 
on both sides the pitch of the sound is higher on the 
left than on the right side. It will be observed that 
these variations correspond to those of the sound 
with expiration in the infra-clavicular region {vide 
p. 96). Occasionally whispered words are partly 
transmitted, constituting incomplete whispering pec- 
toriloquy. 

In the scapular region the bronchial whisper is 
not infrequently wanting. It may be present on the 
right and not on the left side, and if present on both 
sides, it is always louder on the right side. 

In the inter-scapular region, as a rule, it is nearly 
or quite as marked as over the site of the primary 
bronchi in front. The pitch is more or less high, 
and has a tubular quality. It is louder on the right 



108 AUSCULTATION IN HEALTH 

and higher in pitch on the left side, and in this 
situation there may be incomplete pectoriloquy. 

In the infra-scapular region, it is not frequently 
wanting. When present it is generally feeble, the 
pitch being low and the quality non-tubular, or blow- 
ing. It is oftener wanting on the left than on the 
right side, and, if present on both sides, it is louder 
on the right side. 

In the mammary and infra-mammary regions it is 
not infrequently wanting, and the statements just 
made with reference to' the infra-scapular region are 
alike applicable to these, as, also, to the axillary and 
infra-axillary regions. 



CHAPTER V 
AUSCULTATION IN DISEASE 

The respiratory signs of Disease — Abnormal modifications 
of the normal respiratory sounds — Increased vesicular murmur 
— Diminished vesicular murmur — Suppressed respiratory sound 
— Bronchial or tubular respiration — Broncho-vesicular respira- 
tion — Cavernous respiration — Broncho-cavernous respiration — 
Vesiculo-cavernous respiration — Amphoric respiration — Short- 
ened inspiration — Prolonged expiration — Interrupted respira- 
tion — Adventitious respiratory sounds, or rales — Laryngeal 
and tracheal rales — Moist bronchial rales: coarse, fine, and sub- 
crepitant — Vesicular or crepitant rale — Cavernous or gurgling 
rale — Pleural friction rales, metallic tinkling and splashing — 
Indeterminate rales — The vocal signs of disease — Bronchophony 

— Whispering bronchophony — Egophony — Increased vocal 
resonance — Increased bronchial whisper — Cavernous whisper 

— Pectoriloquy — Amphoric voice or echo — Diminished and 
suppressed vocal resonance — Diminished and suppressed vocal 
fremitus — Metallic tinkling — Signs obtained by acts of coughing 
or tussive sounds. 

The importance of becoming perfectly familiar 
with the signs of health before entering upon the 
study of morbid signs, cannot be too strongly en- 
forced. The auscultatory signs of disease, which 
are to be considered in this chapter, should not be 
studied until the student has made himself complete 
master of all the characters belonging to the normal 
signs obtained by auscultation. 



110 AUSCULTATION IN DISEASE 

Auscultation in disease embraces the signs produced 
by respiration, by the voice, and by acts of coughing. 
The respiratory signs will be first considered. 



THE RESPIRATORY SIGNS OF DISEASE 

The morbid signs produced by respiration may be 
classified as follows: 1st. Those which are abnormal 
modifications of the normal respiratory sounds. 2d. 
Those which have no analogues in health, being 
entirely new or adventitious sounds. The latter are 
usually embraced under the name rales. 



ABNORMAL MODIFICATIONS OF THE NORMAL 
RESPIRATORY SOUNDS 

In order to appreciate the distinctive characters 
of the signs embraced in this class, the characters 
which distinguish the normal vesicular murmur must 
be kept in mind. The abnormal modifications which 
characterize these morbid signs relate to intensity, 
pitch, and quality of sound, together with certain 
alterations in rhythm. Twelve signs are included 
under this heading, namely: 1. Increased vesicular 
murmur. 2. Diminished vesicular murmur. 3. Sup- 
pression of respiratory sound. 4. Bronchial or tubu- 
lar respiration. 5. Broncho-vesicular respiration. 6. 
Cavernous respiration. 7. Broncho-cavernous respi- 
ration. 8. Vesiculocavernous respiration. 9. Am- 
phoric respiration. 10. Shortened inspiration. 11. 
Prolonged expiration. 12. Interrupted respiration. 



THE NORMAL RESPIRATORY SOUNDS 111 

These signs are to be studied, first, with reference 
to their distinctive characters severally, each being 
contrasted, as respects these characters, with the 
other morbid respiratory signs as well as wTth the 
normal vesicular murmur; and, second, with refer- 
ence to the morbid physical conditions which they 
severally represent, that is, the diagnostic significance 
which belongs to each. 

Increased Vesicular Murmur. — This sign has but a 
single distinctive character, namely, increase of in- 
tensity. The murmur is abnormally loud, the char- 
acters of the normal vesicular murmur being in other 
respects not materially changed, that is, the pitch is 
low and the quality vesicular as in health. Now, it 
has been seen (vide p. 94) that the intensity of the 
healthy murmur varies much in different persons; 
there is no ideal standard of normal intensity by 
reference to which an abnormal increase is to be 
determined. Yet the increase under certain condi- 
tions of disease is such that the fact is sufficiently 
evident. It occurs on the healthy side of the chest 
when the respiratory function on the other side is 
annulled or much compromised by disease. This 
takes place in cases of pleurisy with large effusion, 
pneumonia, especially if more than one lobe be 
affected, obstruction of one of the primary bronchi, 
and in pneumothorax. The sign does not possess 
great diagnostic importance inasmuch as the nature 
and extent of the disease are ascertained by the signs 
obtained on the affected side. 



112 AUSCULTATION IN DISEASE 

The sign has been called supplementary and puerile 
respiration. 

If the murmur be much intensified, it may possibly 
be mistaken for other morbid signs, namely, bron- 
chial or broncho-vesicular respiration. This error, 
however, can never be made if the distinctive char- 
acters of these signs relating to pitch and quality have 
been correctly studied. 

Diminished Vesicular Murmur. — The intensity of the 
vesicular murmur may be, on the one hand, diminished 
when it is evident that in other respects there is no 
material change, and the murmur, on the other hand, 
may become so feeble that characters aside from the 
intensity are not determinable. From the latter fact 
it follows that the murmur must sometimes be con- 
sidered as only weakened, when, were the diminished 
intensity not as great, morbid changes in pitch and 
quality might be appreciable. 

The murmur is more or less weakened in cases of 
dilatation of the air-cells, or vesicular emphysema, 
the sign, in these cases, being often accompanied by 
changes in rhythm, namely, a shortened inspiration 
and a prolonged expiration. Simple weakness of 
the murmur may also be incident to partial block- 
ing of the air-vesicles with blood or serum in cases 
of pulmonary extravasation and edema. A defi- 
cient expansion of the chest, either on one side or 
on both sides, occasions weakness of the respiratory 
murmur. Deficient expansion of one side, or of both 
sides, may be caused by paralysis, bilateral or unilat- 
eral, of the costal muscles. A similar effect is caused 



THE NORMAL RESPIRATORY SOUNDS 113 

by paralysis of the diaphragm. The incomplete 
descent of the diaphragm from pain, as in peritonitis, 
or from mechanical obstacles, as in peritoneal dropsy, 
pregnancy, and abdominal tumors, weakens the respira- 
tory murmur, the increased action of the costal muscles 
not being fully compensatory. Unilateral deficiency 
of expansion of the chest is caused by pain in inter- 
costal neuralgia, pleurodynia, acute pleurisy, and 
pneumonia; it is also caused by the presence of a 
stratum of liquid, air, or a thick layer of lymph, between 
the lung and the chest-wall in pleurisy, hydrothorax, 
and pneumothorax. Swelling of the bronchial mucous 
membrane in bronchitis affecting the larger tubes, 
must diminish somewhat the intensity of the murmur. 
In primary bronchitis the murmur is diminished on 
both sides. In bronchitis affecting the smaller tubes 
the murmur is greatly diminished, if not suppressed, 
on both sides. Incomplete obstruction of bronchial 
tubes from the presence of mucus, serum, blood, or 
pus, has this effect over an area corresponding to 
the size of the tubes obstructed. Spasm of the bron- 
chial muscular fibres in paroxysms of asthma, dimin- 
ishes, if it does not suppress, murmur on both sides. 
Another cause of diminution, unilateral or within a 
limited space on one side, is the presence of a tumor 
pressing on bronchial tubes, as in cases of aneurysm. 
A permanent contraction or stricture of bronchial 
tubes is another cause. Not infrequently the pressure 
of an aneurismal tumor or an enlarged bronchial gland 
on a primary bronchus, occasions notable weakness 
of the murmur over the whole of one side; and the 
8 



114 AUSCULTATION IN DISEASE 

pressure of a tumor on the trachea weakens the 
murmur, more or less, on both sides. A foreign body 
in one of the primary bronchi weakens it on one side. 
Diminution of the calibre of the trachea or larynx 
from morbid growths, the presence of foreign bodies, 
fibrinous exudations, accumulations of mucus, sub- 
mucous infiltration, spasms of the laryngeal muscles, 
and swelling of the mucous membrane, weakens, in 
proportion to the amount of obstruction, the murmur 
on both sides without any material change in its 
quality and pitch. 

Weakened murmur at the summit of the chest, 
without other appreciable abnormal characters, occurs 
in some cases of phthisis, due to obstructed bronchial 
tubes from coexisting circumscribed bronchitis, or to 
deficient superior costal movements of the chest, as well 
as to the presence of exudation in the air-vesicles. 

Diminished intensity of the vesicular murmur is 
thus seen to be a respiratory sign entering into the 
diagnosis of a considerable number of diseases, namely, 
emphysema, paralysis affecting the respiratory muscles, 
asthma, abdominal affections interfering with the dia- 
phragmatic movements, intercostal neuralgia, pneu- 
monia, fibrinous pleurisy, hydrothorax, bronchitis, 
aneurismal and other tumors, permanent constriction 
or stricture of bronchial tubes, laryngitis, edema of 
the glottis, spasm of the glottis, the various lesions 
which occasion obstruction of the larynx or trachea, 
and phthisis. 

In determining a slight abnormal weakness of the 
respiratory murmur at the summit of the chest on 



THE NORMAL RESPIRATORY SOUNDS 115 

the right side, the normal disparity between the two 
sides in this situation is to be borne in mind. The 
vesicular murmur is normally less intense on the 
right than on the left side. 

This sign occurring in so many diseases, it is obvious 
that, taken alone, that is, independent of other signs, 
it has not any special diagnostic significance. It is, 
however, often of value in diagnosis, when taken in 
connection with other signs. It is chiefly useful when 
it exists either over the whole or in a part of the chest 
on one side. 

Suppressed Respiratory Sound. — This sign is easily 
defined, namely, absence of all respiratory sound, as 
the name signifies. It cannot, of course, have any 
characters relating to intensity, pitch, and quality. 

Suppression of respiratory sound represents the 
same physical conditions as diminished vesicular 
murmur; the physical conditions represented by 
the latter sign, existing in a greater degree, occa- 
sion absence of all sound. It suffices, therefore, to 
recapitulate the various conditions and diseases in 
connection with which the murmur may either be 
diminished or suppressed. Suppression over por- 
tions of the chest may be due to dilatation of the 
air-cells in cases of emphysema. It occurs from the 
exclusion of air from the vesicles by the presence of 
blood and serum in cases of pulmonary extravasa- 
tion and edema. Respiratory sound is sometimes 
wanting over lung solidified in cases of pneumonia 
and phthisis. Paralysis of the muscles concerned 
in respiration may possibly involve feebleness of the 



116 AUSCULTATION IN DISEASE 

respiratory acts sufficiently to render the murmur 
inappreciable. In intercostal neuralgia, pleurodynia, 
acute pleurisy, and pneumonia, the movements of the 
affected side may be so much restricted as to abolish 
the murmur. In pleurisy with much effusion, empyema, 
hydrothorax, pneumothorax, the murmur is suppressed 
over either a part, or the whole of the affected side, 
the extent of the suppression corresponding to the 
quantity of serum, pus, or air within the pleural 
cavity. Swelling of the mucous membrane in cases 
of bronchitis affecting the larger bronchial tubes is 
never sufficient to suppress the murmur, but plugging 
of more or less of the tubes with mucus or other morbid 
products may have this effect. In cases of bronchitis, 
the murmur is sometimes found to have disappeared 
over a certain area, and to return after an act of 
expectoration. In bronchitis affecting the smaller 
tubes, suppression of the murmur is not infrequent. 
It occurs from spasm of the bronchial muscular fibres 
in cases of asthma. The pressure of a tumor, morbid 
growths, or deposits from bronchi, within the lungs, 
may abolish respiratory sound over a portion of the 
chest, and permanent stricture or obliteration of 
bronchial tubes must have this effect. Respiratory 
sound may be suppressed over the whole of one side 
from the pressure of an aneurysmal or some other 
tumor upon one of the primary bronchi. If the tumor 
press upon the trachea, the obstruction may be suffi- 
cient to suppress the murmur on both sides. A foreign 
body lodged in a primary bronchus may suppress the 
murmur on one side, and, lodged in the larynx or 



THE NORMAL RESPIRATORY SOUNDS 117 

trachea, the murmur may be suppressed on both sides. 
The different affections of the larynx and trachea 
which, in proportion to the amount of obstruction, 
weaken the murmur, may render it inappreciable. 

Bronchial or Tubular Respiration. — The analogue of 
this sign is the normal laryngeal or tracheal respi- 
ration (vide p. 92). The characters which distin- 
guish the latter normal sign from the normal vesicular 
murmur, are those which are distinctive of the 
bronchial or tubular respiration. These characters, 
relating to the inspiratory and the expiratory sounds, 
are as follows: The inspiratory sound is of variable 
intensity. Intensity does not enter into the distinc- 
tive characters of this sign; the sound may be either 
louder or weaker than the inspiratory sound in health. 
The pitch of the inspiratory sound is high. The 
quality is expressed by the term tubular; it is like 
the sound produced by blowing through a tube, this 
quality taking the place of that expressed by the term 
vesicular in the normal respiration. The expiratory 
sound is prolonged; it is as long as, or longer than, 
the sound of inspiration, and is usually louder. , The 
pitch is still higher than that of the inspiratory sound. 
The quality, like that of the inspiratory sound, is 
tubular, this quality taking the place of the simple 
blowing quality of the expiratory sound in the normal 
vesicular murmur. With the normal rhythm of the 
respiratory acts there is a very brief interval between 
the sounds of inspiration and expiration, due to the 
fact that the inspiratory sound ends a little before 
the end of the inspiratory act. 



118 AUSCULTATION IN DISEASE 

The morbid physical condition represented by 
this important sign is either complete or consider- 
able solidification of lung. Whenever the chest is 
auscultated over lung solidified, if there be not absence 
of respiratory sound, the sound is tubular. This 
significance renders the sign of diagnostic value in 
the diseases which involve solidification. The sign 
per se denotes simply this morbid physical condition; 
the particular disease which exists is ascertained by 
means of the associated signs and the symptoms. 

Solidification of lung is incident to several dif- 
ferent diseases. In lobar pneumonia it is due to 
a fibrinous exudation within the air-vesicles. In 
phthisis it is caused by an exudation in the same 
situation. In chronic or fibroid pneumonia the lung 
is solidified by an interstitial growth. The com- 
pression of lung from either pleuritic effusion, an 
accumulation of air in the pleural cavity, or the pres- 
sure of a tumor, causes solidification by condensation. 
Collapse of pulmonary lobules also solidifies by conden- 
sation. Coagulation of blood within the air-vesicles 
(hemorrhagic infarctus), and neoplastic infiltration or 
growth, are other causes of solidification. In these 
different affections, if the solidification be complete or 
considerable, this sign is usually present; it is always 
present if there be not suppression of respiratory sound. 

It is sometimes the case that either the inspiratory 
or the expiratory sound is wanting. The characters 
of the sign suffice for its recognition if either the inspi- 
ratory or the expiratory sound be alone present; the 
pitch and the quality are distinctive. Both sounds 



THE NORMAL RESPIRATORY SOUNDS 119 

are often so intense that they are diffused more or 
less without the limits of the solidified portion of 
lung. The expiratory sound, being more intense than 
the inspiratory, is transmitted farther than the latter. 
This explains the conjunction sometimes of a vesicular 
inspiration with a tubular expiration; and a cavernous 
inspiration may be conjoined with a tubular expira- 
tion, showing the proximity of solidified lung in the 
former case to healthy lung, and in the latter case 
to a pulmonary cavity. 

The sound may seem near the ear, or to come from 
a certain distance. The latter is appreciable in some 
cases of large pleuritic effusion; the tubular respira- 
tion is more or less distant, and it is sometimes 
diffused over the whole of the side which is filled 
with liquid. 

Broncho-vesicular Respiration. — This name was intro- 
duced by me, in 1856, to denote the combination, 
in varying proportions, of the characters of the bron- 
chial or tubular, and of the normal vesicular respira- 
tion. The name expresses such a combination. It 
embraces modifications to which have been applied 
the terms, rude, rough, and harsh respiration, and 
those included by German authors under the name 
indeterminate respiratory sounds. 

The sign represents the different degrees of solidi- 
fication of lung, between an amount so slight as to 
occasion only the smallest appreciable modification 
of the respiratory sound, and an amount so great as 
to approximate closely to the degree giving rise to 
bronchial or tubular respiration. In other words, 



120 AUSCULTATION IN DISEASE 

all the gradations of respiratory modifications, caused 
by incomplete or an inconsiderable solidification, 
which fall short of bronchial or tubular respiration, 
are embraced under the name broncho-vesicular. 
The gradations correspond to the amount of solidi- 
fication, that is, they show the solidification to be 
either very slight, slight, moderate, or nearly suffi- 
cient to be considered as considerable or complete. 
The sign is, therefore, important as evidence, first, 
of the existence of solidification; and, second, of the 
degree of solidification. 

Analyzing this sign, the most distinctive feature 
is the combination of the vesicular and the tubular 
quality in the respiratory sound. These two quali- 
ties may be combined in variable proportions. The 
pitch of the sound is raised in proportion as the tubular 
predominates over the vesicular quality. The expira- 
tory sound is more or less prolonged, tubular in quality, 
and the pitch is raised. The prolongation of this 
sound, its tubular quality, and the highness of pitch, 
are proportionate to the predominance of the tubular 
over the vesicular quality in the inspiratory sound. 
If the solidification of lung be slight, the characters 
of the normal vesicular respiration predominate; that 
is, the inspiratory sound has but a small proportion 
of the tubular quality, and is but little raised in pitch, 
the expiratory sound being not much prolonged, its 
tubularity not marked, the pitch not high. If, on 
the other hand, the solidification of lung be almost 
enough to give a bronchial respiration, the inspiratory 
sound has only a little vesicular quality, the tubular 



THE NORMAL RESPIRATORY SOUNDS 121 

quality predominating, the pitch proportionately 
raised; and the expiratory sound is prolonged, tubular, 
and high, nearly to the same extent as in the bronchial 
respiration. The less the solidification, the more the 
characters of the normal vesicular predominate over 
those of the bronchial respiration, and, per contra, 
the greater the solidification the more the characters 
of the bronchial predominate, over those of the nor- 
mal vesicular respiration. Daily auscultation in a 
case of lobar pneumonia during the stage of resolu- 
tion affords an opportunity to study all the grada- 
tions of this sign. After resolution has made some 
progress the inspiratory sound is no longer purely 
tubular, but the ear appreciates a little admixture of 
the vesicular quality and the pitch is slightly lowered. 
As resolution goes on the vesicular quality increases, 
the pitch is correspondingly lowered, until, at length, 
no tubularity remains, and the pitch becomes normal. 
Meanwhile, as the vesicular quality increases in the 
inspiratory sound, the expiratory sound is less and 
less prolonged, high and tubular, until it becomes, as 
in health, short, low, and blowing. 

The broncho-vesicular respiration is an important 
diagnostic sign in all the affections which involve 
partial solidification of lung. In lobar pneumonia, 
as just stated, it denotes the progress made from day 
to day in resolution. It is found also in an earlier 
stage, before the solidification is sufficient to give 
rise to a purely bronchial respiration. It is a valu- 
able sign in phthisis, affording evidence, not only of 
the fact of solidification, but of its degree and extent. 



122 AUSCULTATION IN DISEASE 

The sign enters into the diagnosis of interstitial pneu- 
monia, hemorrhagic infarctus, condensation of lung 
from the pressure of either liquid, air, or a tumor, 
and from collapse of pulmonary lobules. It may be 
stated with respect to this sign, that it is always 
present if the lung be partially solidified, provided 
there be not either suppression of respiratory sound, 
or such a degree of feebleness that the distinctive 
characters are undeterminable. As with the bron- 
chial respiration, so with the broncho-vesicular, either 
the inspiratory or the expiratory sound may be want- 
ing. The characters of the sign are then to be deter- 
mined as they are manifested in the sound which is 
present, namely, the combination of the vesicular 
and the tubular quality, with more or less elevation 
of pitch, if only an inspiratory sound may be heard, 
and the amount of prolongation, tubularity, and eleva- 
tion of pitch, if there be only an expiratory sound. 

In determining the presence of this morbid sign 
at the summit of the chest on the right side, it is to 
be borne in mind that the respiratory murmur on 
this side has, in health, as compared with the respi- 
ratory murmur at the summit on the left side, more 
or less of the characters of the broncho-vesicular 
respiration (vide Normal Broncho-vesicular Respira- 
tion, p. 119). 

Cavernous Respiration. — The modifications which 
constitute the distinctive characters of this sign are 
produced by the entrance of air into a cavity with 
the act of inspiration, and its exit from the cavity 
with the act of expiration. This passage of air into 



THE NORMAL RESPIRATORY SOUNDS 123 

and from a cavity can only take place where the 
walls of the cavity collapse more or less in expira- 
tion and expand in inspiration. Pulmonary cavities 
occur chiefly in cases of phthisis. They occur, but 
with comparative infrequency, as a result of circum- 
scribed abscess and gangrene of lung. 

A well-marked cavernous respiration has char- 
acters which are highly distinctive when this sign is 
contrasted, on the one hand, with either the bron- 
chial or broncho-vesicular respiration, and, on the 
other hand, with the normal vesicular murmur. These 
distinctive characters relate both to the inspiratory 
and expiratory sound. The inspiratory sound is 
neither vesicular nor tubular in quality, and the 
pitch is low as compared with the bronchial respira- 
tion. As regards quality, we may say of it, as of 
the expiratory sound in the normal vesicular respi- 
ration, it is simply a blowing sound. The expira- 
tory sound has the same quality as the inspiratory, 
and it is lower in pitch. Its duration is variable. 
The intensity of both the inspiratory and the expi- 
ratory sound varies; intensity does not enter into 
the distinctive characters of this sign more than into 
those of the bronchial and the broncho-vesicular 
respiration. With a practical knowledge of the fore- 
going characters distinctive of the cavernous respira- 
tion, there is no difficulty in discriminating this sign 
from the bronchial respiration. The sign is more 
likely to be confounded with the normal vesicular 
murmur, inasmuch as it differs from the latter only in 
the absence in the inspiratory sound of the vesicular 



124 AUSCULTATION IN DISEASE 

quality. Against this error the student is to be cau- 
tioned. It is most likely to be made when the inspira- 
tory sound is much weakened, and, consequently, 
the vesicular quality less distinctly appreciable than 
when the sound is more or less intense. 

A cavernous respiration is limited to a space more 
or less circumscribed, the area corresponding to the 
site and the size of the cavity. Occurring, for the 
most part, in cases of phthisis, it is much oftener 
found at the summit than elsewhere over the chest. 
It is not constantly found where there is a cavity with 
flaccid walls. It may be temporarily suppressed by the 
presence of liquid within the cavity, and by obstruc- 
tion of the orifices communicating with bronchial 
tubes, or of the latter. It may be wanting at one 
moment, and an act of expectoration may cause 
it to reappear. Hence absence of cavity cannot be 
predicated on the absence of the sign at a single exami- 
nation. Moreover, if a cavity be not situated near 
the pulmonary superficies, and solidified lung inter- 
vene between it and the walls of the chest, the caver- 
nous sign may be drowned in a loud bronchial respira- 
tion. For this reason, while the cavernous sign is 
positive evidence of a cavity, the absence of the sign 
is not proof that a cavity does not exist. 

In some cases of perforation of lung with pneumo- 
thorax, the passage of air to and fro through the per- 
foration may give rise to the cavernous respiration. 
As a rule, however, under these circumstances, another 
sign is produced, namely, the amphoric respiration. 

The cavernous respiration may be reproduced by 



THE NORMAL RESPIRATORY SOUNDS 125 

the inflation of lungs after their removal from the 
body, the binaural stethoscope being placed over a 
cavity. This is true, also, of the bronchial and the 
broncho-vesicular respiration. These signs may be 
thus illustrated not infrequently after death from 
phthisis, in lungs in which are cavities together with 
portions completely or moderately solidified. 

The distinctive characters of the cavernous respi- 
ration may also be illustrated by means of a small 
India-rubber balloon with openings at opposite 
ends. Inflating the balloon through a tube introduced 
into one opening produces a sound analogous to the 
cavernous inspiration, and the expulsion of the air 
by the elasticity of the balloon produces a sound 
analogous to the cavernous expiration. A Davidson's 
syringe may be used to inflate the balloon. The 
sounds are heard by applying lightly to the balloon the 
binaural stethoscope. This illustration demonstrates 
the mechanism of the cavernous respiration. 

Broncho-cavernous Respiration. — In this sign, as the 
name denotes, the characters of the bronchial and 
the cavernous respiration are combined. These 
characters may be combined in different ways, as 
well as in variable proportions. If a cavity be situ- 
ated in proximity to solidified lung, the quality and 
pitch of the inspiratory and the expiratory sound 
may show an admixture of the characters of the two 
signs, and to a practised ear the combination is dis- 
tinctly recognizable. This is one of the forms of 
broncho-cavernous respiration; the sounds are not 
sufficiently high and tubular for bronchial, nor suffi- 



126 AUSCULTATION IN DISEASE 

ciently low and blowing for cavernous respiration. 
Another form consists of an inspiratory sound, the 
first part of which is tubular, and the latter part 
cavernous. Examples of this form are not extremely 
infrequent (metamorphosing respiration) . Still another 
form is a cavernous inspiratory, with a bronchial or 
tubular expiratory sound. In the latter form, the 
bronchial expiration proceeds from solidified lung 
situated near the cavity, the intensity of the sound 
being sufficient to drown the cavernous expiration. 

When, as often happens, a cavity is situated in 
close proximity to, or, it may be, surrounded by solidi- 
fied lung, the cavernous and the bronchial respira- 
tion are, as it were, in juxtaposition, and such instances 
offer an excellent opportunity to study the points 
distinguishing these signs from each other; and, gener- 
ally, at a short distance the normal vesicular murmur 
may be found, so that both morbid signs may be 
compared with the latter. Within a circumscribed 
area sometimes are exemplified the characters of the 
normal murmur, and of the two morbid signs just men- 
tioned, together with those of the broncho-vesicular 
respiration. 

Vesiculo-cavernous Respiration. — It is sometimes evi- 
dent that the vesicular and the cavernous quality are 
combined in the inspiratory sound. This occurs 
when a cavity is surrounded, not by solidified, but 
by healthy lung. Under these circumstances, over 
the site of the cavity the inspiratory sound may be 
as loud as, or louder than, that around the cavity, 
but the quality is not purely cavernous; some vesic- 



THE NORMAL RESPIRATORY SOUNDS 127 

ular quality is appreciable. A vesiculocavernous 
respiration, then, is a cavernous respiration plus 
some vesicular quality derived from the air-vesicles 
which are proximate to the cavity. This sign is 
corroborated by other associated signs showing the 
existence of a cavity and its localization. 

Amphoric Respiration. — The term amphoric has a 
significance when applied to auscultatory sounds, 
analogous to that which it has in percussion; it denotes 
a musical intonation which may be compared to 
the sound produced by blowing upon the open mouth 
of a decanter or phial. Whenever the respiratory 
sound has this intonation, it denotes a space contain- 
ing air which is not expelled with the act of expira- 
tion. Air in the pleural cavity, with perforation 
of lung, is the physical condition most frequently 
represented by this sign. It is a valuable diagnostic 
sign in cases of pneumothorax; but it is not always 
present in that affection, certain accessory conditions 
being requisite — namely, perforation above the level 
of liquid, and an unobstructed communication of the 
bronchial tubes, through the opening, with the pleural 
space containing air. While, therefore, its presence is 
significant of pneumothorax, its absence is by no means 
sufficient to exclude this affection. Not infrequently it 
is a sign of a phthisical cavity with rigid walls which 
do not collapse with the act of respiration. The same 
contingencies affect its production here as in cases 
of pneumothorax. Whenever amphoric respiration is 
present, if pneumothorax be excluded by the absence 
of the other signs which are diagnostic of this affection, 



128 AUSCULTATION IN DISEASE 

the sign is proof of the existence of a pulmonary cavity, 
the walls of which are not flaccid. The sign then takes 
the place of the ordinary cavernous respiration which 
has been described. 

The amphoric sound may accompany either inspi- 
ration or expiration, or both. Amphoric respiration 
may be artificially illustrated by connecting an India- 
rubber bag of considerable size (such as is contained 
within a foot-ball) with a flexible tube, and after 
dilating it with air, inflating it forcibly either by a 
pair of bellows or by the mouth, holding the bag 
close to the ear. The amphoric sound thus produced 
represents the amphoric respiration as a sign in pneu- 
mothorax. As the sign of a tuberculous cavity it may 
be illustrated by a similar experiment, using an India- 
rubber bag of the size of an egg or orange. I have 
localized a tuberculous cavity with rigid walls in 
the centre of a lobe, by inflating artificially phthisical 
lungs after their removal from the body. 

Shortened Inspiration. — The inspiratory sound is 
somewhat shortened in bronchial or tubular respira- 
tion. This modification enters into the characters 
of that sign, the quality of the sound being tubular, 
and the pitch high. The shortening is due to the 
sound ending before the inspiratory act ends; the 
sound is said to be unfinished. Shortening of the 
sound occurs, however, when it is not an element 
in the bronchial respiration. The shortening is then 
due to the sound not beginning with the inspira- 
tory act; this is distinguished as deferred inspira- 
tory sound. A deferred inspiratory sound not tubular 



THE NORMAL RESPIRATORY SOUNDS 129 

in quality, but more or less vesicular, and not notably 
raised in pitch, is a sign of pulmonary or vesicular 
emphysema. It is a sign of value in connection with 
the diagnosis of that disease. 

The student should note the distinctions just stated, 
which relate to pitch and quality. Suppose an inspira- 
tory sound to be present without an expiratory sound ; 
if the sound be shortened at the end of the inspira- 
tion, the pitch high, and the quality tubular, it is bron- 
chial respiration, denoting complete or considerable 
solidification of lung; but if the shortening be at the 
beginning of inspiration, the pitch comparatively low, 
and vesicular quality be appreciable, the sign denotes 
emphysema. The differential points thus are, the 
inspiratory sound either unfinished or deferred, the 
pitch either high or low, and the quality either tubular 
or vesicular. Attention to these points is essential 
in order to avoid error in the interpretation of the 
sign. 

Prolonged Expiration. — The length of the expira- 
tory sound in health varies in different persons. The 
sound is sometimes considerably prolonged; it may 
be nearly as long as the sound of inspiration. There 
is no difficulty in recognizing this as a normal pecu- 
liarity, from the fact that the murmur has the pitch 
and quality of health. An unusual length of the 
expiratory sound, within the range of health, is usually 
observed at the summit of the chest, and especially 
on the right side. It is important to bear in mind 
that at the summit of the chest on the right side, and 
sometimes also on the left side, a prolonged expiratory 
9 



130 AUSCULTATION IN DISEASE 

sound, more or less raised in pitch, and tubular in 
quality, may be a normal peculiarity. It follows that 
a prolonged, and even a high and tubular expiration 
at the summit of the chest, must not be reckoned as 
a morbid sign unless it be associated with other signs 
denoting disease. The laws of the disparity between 
the two sides of the chest at the summit are to be 
taken into account (vide p. 96). If the expiration 
be longer on the left than on the right side, it is 
abnormal; so, also, is a high-pitched tubular expiration 
heard on the left and not on the right side. 

The significance of an abnormally prolonged expira- 
tion depends on its pitch and quality. If it be high 
and tubular, it denotes solidification of lung. It is, 
in fact, bronchial respiration. As already stated, in 
bronchial or tubular respiration the inspiratory sound 
is sometimes wanting, and the presence of the sign 
is then to be determined by the characters, relating 
to pitch and quality, of the expiratory sound. The 
same statement holds true with respect to broncho- 
vesicular respiration when this approximates to the 
bronchial. At the summit of the chest, the characters 
of the inspiratory sound, and associated morbid signs, 
always enable the auscultator to determine whether 
a prolonged high and tubular expiration be, or be not, 
abnormal. A prolonged expiration, which is low in 
pitch and blowing in quality, that is, with the char- 
acters of health, aside from length, may belong to a 
cavernous expiration. This is to be determined by 
the characters of the inspiration, and by other asso- 
ciated signs. Exclusive of cavernous respiration, an 



THE NORMAL RESPIRATORY SOUNDS 131 

abnormally prolonged expiratory sound of low pitch 
and non-tubular, denotes vesicular emphysema. It 
is associated then with a weakened and deferred 
inspiratory sound. A prolonged expiratory sound, in 
cases of emphysema, is invariably low and non-tubular. 
If it have not these characters, it is not a sign of 
emphysema, but belongs to bronchial or broncho- 
vesicular respiration. Attention to these differential 
points is to be enjoined upon the student. 

A prolonged expiration at the summit of the chest 
on the right side is sometimes incorrectly considered 
to be evidence of phthisis. It is to be recollected, 
in the first place, that prolongation of this sound 
with a normal pitch and quality, is never evidence 
of solidification of lung either from phthisis or any 
other disease; and in the second place, even if the 
pitch be high, and the quality tubular, that it is not 
to be regarded as abnormal provided the inspiratory 
sound is unchanged, and other signs of disease are 
not present. At times in bronchitis, there is a pro- 
longed expiratory sound which may be distinguished 
as a sonorous expiration, not amounting to a rale. 
This is likely to be mistaken for broncho-vesicular 
breathing. 

Interrupted Respiration. — To this sign have been 
applied other names, such as jerking, wavy, cogged 
wheel, and by French writers the names entrecoupee 
and saccadee. The modification is either of the 
inspiration or of the expiration, or of both. The 
inspiratory, however, much more frequently than the 
expiratory, sound is interrupted. The sound, instead, 



132 AUSCULTATION IN DISEASE 

of being continuous, is broken into one, two, or more 
parts. This is the characteristic of the sign. If at 
the same time there be alterations in pitch and quality, 
the interruption is merely incidental to other signs — 
namely, the bronchial, broncho-vesicular, or cavernous 
respiration. To constitute it a distinct sign, the inter- 
ruption must be the only appreciable change. As 
a distinct sign it has but little diagnostic value. 

Interrupted respiration is sometimes found in 
healthy persons. It is confined to the summit of 
the chest, and oftener on the left than the right side. 
Existing without any other signs, therefore, it is not 
evidence of disease. It is of value only in the diag- 
nosis of phthisis. Associated with other signs, when 
the latter are not marked, it is entitled to a certain 
amount of weight in the diagnosis. 

Interrupted respiratory sounds, of course, occur 
when there is interruption in the respiratory move- 
ments. This happens in cases of pleurisy, pleuro- 
dynia, or intercostal neuralgia. Owing to the pain 
caused by the movements in respiration, the patient 
may breathe, not continuously, but with a series of 
jerking movements. Sometimes interrupted breath- 
ing is observed in persons who are excited or agitated 
when auscultation is practised. In all these instances 
interruption in the respiratory sounds is found over 
the whole chest, whereas, when it is an abnormal 
sign in cases of phthisis, it is limited to the summit 
on one side of the chest, and there is no interruption 
manifested in the mode of breathing. 



ADVENTITIOUS RESPIRATORY SOUNDS 133 

Summary. — Reviewing the foregoing signs, they may 
be distributed into three classes, as follows: (1) Signs, 
the distinctive characters of which relate either to 
the absence or to the intensity of sound. This class 
embraces (a) increased intensity of the vesicular 
murmur; (b) diminished intensity of the vesicular 
murmur; and (c) suppression of respiratory sound. 
(2) Signs, the distinctive characters of which relate 
especially to pitch and quality. In this class belong 
(a) bronchial or tubular respiration; (b) broncho- 
vesicular respiration; (c) cavernous respiration; (d) 
broncho-cavernous respiration; (e) vesiculo-cavernous 
respiration; and (/) amphoric respiration. (3) Signs, 
the distinctive characters of which relate especially 
to rhythm — namely, (a) shortened inspiration; (&) 
prolonged expiration; and (c) interrupted respiration. 



ADVENTITIOUS RESPIRATORY SOUNDS, OR RALES 

Adventitious respiratory sounds, or, adopting the 
French term, rales, are distinguished from the morbid 
signs already considered, by the fact that they have 
no analogues in health; in other words, they are not 
normal sounds abnormally modified, but wholly new 
sounds. A convenient classification of these signs 
is based on the different anatomical situations in 
which they are produced. This classification is as 
follows: (1) Laryngeal and tracheal rales; (2) bron- 
chial rales; (3) vesicular rales; (4) cavernous rales; 
(5) pleural rales; and (6) indeterminate rales. Com- 
pared with each other, as regards their characters, 



134 AUSCULTATION IN DISEASE 

they admit of being divided into dry and moist 
rales, the latter being evidently due to the presence 
of liquid. 

Laryngeal and Tracheal Rales. — The rales produced 
within the larynx and trachea may be either moist 
or dry. The moist or bubbling sounds are produced 
when mucus or other liquid accumulates in these 
sections of the air-tubes. This occurs frequently 
in the moribund state, and the sounds are then known 
as the "death-rattles/' When not incident to this 
state, they denote either insensibility to the presence 
of liquid, as in coma, or inability to effect the removal 
of the liquid by acts of expectoration. The sounds 
are heard at a distance. They exemplify, on a large 
scale, moist or bubbling auscultatory sounds which 
are produced within the bronchial tubes. Dry sounds 
produced within the larynx or trachea are caused by 
spasm of the glottis, and by diminution of the calibre, 
either at or below the glottis, from edema, exuda- 
tion, the presence of a foreign body, or the pressure 
of a tumor. The dry sounds are distinguished as 
whistling, wheezing, crowing, whooping, etc. They 
are heard at a distance, and they also exemplify aus- 
cultatory sounds representing analogous conditions in 
the bronchial tubes. Characteristic sounds, produced 
at the glottis by spasm, enter into the diagnosis of 
certain affections — namely, laryngismus stridulus, 
pertussis, croup, and aneurism involving excitation of 
the recurrent laryngeal nerve. Other sounds are due 
to paralysis of the laryngeal muscles. Again, dry 
sounds produced by stenosis of the trachea from the 



MOIST BRONCHIAL RALES 135 

pressure of an aneurismal or other tumor, cicatrization 
of ulcers, and morbid growths, are of diagnostic impor- 
tance. Although audible without auscultation, these 
different sounds, with reference to the precise situa- 
tion at which they are produced, may sometimes be 
studied with advantage by means of the stethoscope. 
They are embraced under the name stridor. The 
respiration, voice, and cough, when accompanied by 
these sounds, are said to be stridulous. 

MOIST BRONCHIAL RALES 

The moist bronchial rales are bubbling sounds 
produced in different branches of the bronchial tree. 
They are sounds of which the "tracheal rattles" are 
an exaggerated type. They may be imitated by 
blowing into liquids through tubes differing in size. 
They may also be produced in the lungs of the sheep 
or the calf, after removal from the body, by injecting 
into the bronchi glycerin or some other liquid, and 
imitating the respiratory acts by means of a pair of 
bellows, auscultation being practised with the stetho- 
scope applied upon the surface of the lung, or with 
several thicknesses of cloth intervening. The bubbles 
seem to be large or small according to the size of the 
bronchial tubes in which they are produced. Apparent 
differences in the size of the bubbles are distinguished 
by the names coarse and fine. In the primary and 
secondary bronchial branches the moist sounds are 
relatively quite coarse; they are less so in tubes of 
the third or fourth dimensions; in smaller tubes they 



136 AUSCULTATION IN DISEASE 

become fine, and in those of minute size they become 
extremely fine. 

Extremely fine bubbling sounds constitute what has 
been known as the subcrepitant rale, so-called because 
it approaches in character to the crepitant rale, pro- 
duced within the air- vesicles and bronchioles. We 
may thus judge of the size of the bronchial tubes in 
which the rales are produced by their comparative 
coarseness or fineness. Frequently, however, coarse 
and fine rales are intermingled, and generally, those 
which are either coarse or fine are not uniform, but 
appear to be of unequal size. In all the varieties of 
the moist bronchial rales, the bubbling character of the 
sounds is sufficiently distinctive for their recognition. 
The differentiation of the so-called subcrepitant from 
the crepitant rale alone involves some nice points of 
distinction. 

Coarse bubbling rales sometimes occur in acute 
bronchitis affecting the larger bronchial tubes. Their 
occurrence is exceptional, because, in general, the 
mucus within the tubes does not accumulate suffi- 
ciently and is too consistent for the production of 
bubbling sounds. These rales occur in cases in which 
the mucus is unusually thin, and either more abundant 
than usual, or an accumulation takes place in conse- 
quence of inability to expectorate freely. These 
conditions are wanting in the majority of the cases 
of ordinary acute bronchitis. A muco-purulent liquid 
in cases of chronic bronchitis is better suited for the 
production of bubbling sounds than simple mucus. 
Moreover, coarse rales are heard oftener in children 



MOIST BRONCHIAL RALES 137 

than in adults, because the former do not voluntarily 
expectorate as freely as the latter. Serous transuda- 
tion (bronchorrhea) into tubes of large size may give 
rise to coarse bubbling rales, and also the presence of 
blood in some cases of profuse hemorrhage. In bron- 
chitis and bronchorrhea the rales are heard on both 
sides of the chest. The bubbling rales, whether coarse 
or fine, are heard either with the act of inspiration or 
of expiration, or with both acts. 

Fine bubbling sounds and the so-called subcrepi- 
tant rale occur in various pathological connections. 
The characters of the latter are to be borne in mind 
with reference to the discrimination from the crepi- 
tant rale. The most distinctive character is the 
moist sound or bubbling; this is sufficiently appre- 
ciable. Other characters are, their occurrence fre- 
quently, but not constantly, in expiration as well as 
in inspiration, and the inequality of the fine bubbling 
sounds. 

The so-called subcrepitant rale, existing over the 
chest on both sides, is diagnostic of bronchitis affect- 
ing the smaller bronchial tubes (capillary bronchitis), 
when taken in connection with other signs, and the 
symptoms. The rales exist on both sides, because 
this, as w^ell as bronchitis affecting the larger tubes, 
is a bilateral affection. The sign is of great prac- 
tical value in the diagnosis of that variety of bron- 
chitis. The rale also occurs on both sides, and is 
more or less diffused in pulmonary edema. The 
connection with the latter affection is shown by the 
associated physical signs, together with the symp- 



138 AUSCULTATION IN DISEASE 

toms. In so-called capillary bronchitis, the bubbling 
is due to the presence of thin mucus, and in pulmo- 
nary edema to serous transudation within the small 
bronchial ramifications. 

Fine bubbling or the so-called subcrepitant rale has 
other pathological connections, as follows: 

1. It occurs in lobar pneumonia during the stage 
of resolution. Here it is due to the presence of mucus 
from a bronchitis limited to the affected lobe or lobes, 
and, in a measure, to liquefied pneumonic exudation. 
It is considered as denoting commencing, and pro- 
gressing resolution in pneumonia. Sometimes it is 
intermingled with rales which are more or less coarse. 

2. In circumscribed pneumonia, hemorrhagic infarc- 
tus, and pulmonary apoplexy, the fine or subcrepitant 
rale, often associated with those which are more or 
less coarse, denotes the presence of mucus or of blood 
within the bronchial tubes. The rales are localized 
in space, or in spaces, corresponding to the situation 
and extent of the affection. 

3. During and shortly after a hemoptysis, fine 
rales limited to a particular situation are sometimes 
heard, proceeding from blood in the small bronchial 
tubes, and indicating the situation of the hemorrhage. 

4. A purulent liquid admits of bubbling much more 
readily than mucus; hence, in cases of chronic bronchitis 
with an expectoration of pus, fine and coarse bronchial 
rales are more frequent than in acute bronchitis. Pus, 
also, may be present within bronchial tubes of small 
size, not as a product of bronchitis, but from the 
evacuation of an abscess of either the pulmonary 



MOIST BRONCHIAL RALES 139 

parenchyma, of the liver, or some other adjacent part, 
and from perforation of lung in some cases of empyema. 

5. In the different stages of phthisis, moist bron- 
chial rales are usually present. The liquid in the 
tubes, if the disease be advanced, is derived, in part, 
from associated bronchitis, and, in part, from lique- 
fied tuberculous exudation. The bubbling sounds 
may be more or less coarse or fine, and both are often 
intermingled. Early in the disease, before softening 
of the exudation has taken place, fine bubbling, or 
the subcrepitant rale, limited to the summit of the 
chest, is an important diagnostic sign. This fine 
subcrepitant rale in early pulmonary tuberculosis is 
heard also, and not infrequently, at the tip of the 
lower lobes behind, in the inter-scapular regions. It 
belongs among the accessory physical signs on which 
the diagnosis may depend. Here the liquid is derived 
from a coexisting circumscribed bronchitis. 

In cases of fibroid phthisis, or cirrhosis of lung, 
moist rales, coarse and fine, are generally more or 
less abundant and diffused over the whole, or the 
greater part, of the chest on the affected side. 

In the foregoing account of the moist bronchial 
rales, the subcrepitant rale is not reckoned as a sign 
distinct from fine bubbling sounds. Inasmuch as the 
mechanism and the significance are the same, and it 
is not easy to draw a line of demarcation between 
the two, the distinction is unimportant. It is suffi- 
cient to bear in mind that very fine bubbling sounds 
are called subcrepitant, because they are somewhat 
analogous to the crepitant rale. The points which 



140 AUSCULTATION IN DISEASE 

distinguish the latter are, however, well marked, as 
will appear when the characters of that sign are con- 
sidered. The term subcrepitant gives rise to confusion, 
and there is no advantage in retaining it as the name 
of a distinct sign. Very fine bubbling expresses more 
correctly the characters of the sign. The moist rales 
are often called mucous rales. This name is obviously 
inappropriate, since, not only are the sounds produced 
by other liquids than mucus, but other liquids are 
best suited for their production, especially in the 
large and medium-sized tubes. 

The several varieties of the moist bronchial rales 
may be produced by the injection of a liquid in vary- 
ing quantity into the bronchi of the lungs removed 
from the body of an aminal of sufficient size, e. g., 
of the sheep or calf, and imitating respiration by 
means of bellows. 

The moist bronchial rales, whether coarse or fine, 
vary in pitch accordingly as the lung surrounding 
the tubes in which they are produced is or is not 
solidified. If the lung be solidified, the pitch is high; 
if there be no solidification, the pitch is comparatively 
low. Thus the pitch of the rales is high in the second 
stage of pneumonia and in phthisis with considerable 
solidification, whereas the pitch is low in bronchitis 
and pulmonary edema. If, therefore, the respiratory 
sound be suppressed, it is easy to determine by the 
pitch of these rales whether the lung be solidified or 
not, and to judge measurably of the degree of solidi- 
fication. Attention to the pitch in connection with 
these rales is sometimes of value in diagnosis. 



DRY BRONCHIAL RALES 141 

DRY BRONCHIAL RALES 

All adventitious sounds which are not moist, pro- 
duced within the air-tubes below the trachea, are 
embraced under the name dry bronchial rales. The 
sounds are many and varied in character. They are 
often musical notes. Frequently they are sugges- 
tive of certain familiar sounds, such as the chirping 
of birds, the cry of a young animal, snoring in sleep, 
cooing of pigeons, humming of the mosquito, the 
note of the violoncello, etc. They are often heard 
at a distance, and characterized as wheezing sounds. 
An interrupted or clicking sound is not uncommon. 
All these varieties are practically unimportant, and 
it would be a needless refinement to consider partic- 
ular varieties as distinct signs. The only distinction 
which it is desirable to make is into the sibilant 
and sonorous rales. This distinction is based on differ- 
ence in pitch; sibilant rales are high, and sonorous 
rales are low in pitch. As a rule, the sibilant rales 
are produced in the small and the sonorous rales 
in the larger sized bronchial tubes. The sounds may 
accompany either inspiration or expiration, or both. 
The sibilant and sonorous rales are often intermingled. 
There may be sibilant rales with inspiration, and 
sonorous rales with expiration, within the same situa- 
tion. Moreover, these rales are found often to vary 
from minute to minute, being at one instant sibilant, 
and at another sonorous. Students are likely to 
confound sonorous rales with bronchial breathing, 
and sometimes with friction-sounds. 



142 AUSCULTATION IN DISEASE 

The physical condition represented by the dry 
rales is diminished calibre of the air-tubes at certain 
points, and especially in consequence of spasm of 
the bronchial muscular fibres. The latter consti- 
tutes the essential pathological condition in a par- 
oxysm of asthma; and in this affection the dry rales 
are always marked. Their diagnostic importance 
relates chiefly to asthma. Both sibilant and sonor- 
ous rales are present and diffused over the entire 
chest. Wheezing sounds with expiration are heard 
by the patient, and by others at a distance. A single 
paroxysm of asthma affords an opportunity for the 
student to observe all the varieties and fluctuations of 
these rales. Taken in connection with other signs and 
symptoms, the rales are pathognomonic of asthma. 

More or less spasm of the bronchial muscular fibres 
occurs in certain cases of bronchitis, without being 
sufficiently great and extensive to give rise to a par- 
oxysm of asthma, or even any embarrassment of 
respiration. Under these circumstances the rales 
are less marked and diffused. An asthmatic element 
may be said to enter, more or less, into these cases. 
Narrowing of bronchial tubes by tenacious mucus 
which gives rise to no bubbling sounds, and, perhaps, 
unequal swelling of the mucous membrane, may also 
occasion sibilant and sonorous rales. 

Dry rales at the summit of the chest are not infre- 
quent in cases of phthisis due to spasm, the presence 
of mucus, or to swelling of the mucous membrane. 
They are sometimes quite annoying to phthisical 
patients. 



VESICULAR OR CREPITANT RALE 143 

Clicking sounds are suggestive of the sudden sep- 
aration of tenacious mucus from the walls of the 
bronchial tubes. These are sufficiently common in 
bronchitis and in phthisis. 

VESICULAR OR CREPITANT RALE 

This is the only vesicular rale. It is usually con- 
sidered to be produced within the air-vesicles, but 
probably the terminal bronchial tubes or bronchioles 
participate in its production. 

It is to be distinguished from very fine bubbling 
sounds, or the so-called subcrepitant rale. The points 
of distinction are as follows: The sounds are not 
moist but dry; they are crackling, not bubbling in 
character. They may be defined to be very fine, 
dry, crackling sounds. This point of difference is 
very distinctive. There are, however, other differ- 
ential points. The crackling sounds are equal, whereas, 
fine bubbling sounds are unequal, that is, they give 
the impression of bubbles of unequal size. The crepi- 
tating sounds are heard at the end of the inspiratory 
act, and especially at the end of a forced inspiration, 
the subcrepitant rale, on the other hand, being heard 
often with or near the beginning of inspiration, and, 
perhaps, ceasing before the end of the inspiratory 
act. Another distinctive feature is the abrupt develop- 
ment of the crepitant rale; there is a shower of crackles, 
as it were, at the end of a forced inspiration. Finally, 
the rale is never heard in expiration. The apparent 
exceptions to this statement are instances in which the 



144 AUSCULTATION IN DISEASE 

crepitant and the subcrepitant rale are associated. 
This is not very infrequent, and, with a practical 
knowledge of the characters of each, it is by no. means 
difficult to appreciate the combination of the two signs. 
In fact, the combination affords an excellent oppor- 
tunity to illustrate the distinctive characters of each; 
the fine bubbling at or near the beginning of inspira- 
tion, followed by the fine crackling at the end of this 
act, and the former perhaps reproduced in the act of 
expiration. 

There are various modes in which the crepitant 
rale may be imitated; for example, rubbing together 
a lock of hair near the ear, throwing fine salt upon 
live coal or into a heated vessel, igniting a train of 
gunpowder, and alternately pressing and separating 
the thumb and finger moistened with a solution of 
gum arabic and held near the ear. A perfect repre- 
sentation is afforded by squeezing a piece of an artificial 
preparation known as the India-rubber sponge, and 
observing the sound produced by the separation of 
the walls of the interstices when the piece expands 
from its elasticity. This preparation exemplifies 
the true mechanism of the sign as described, first, 
by the late Dr. Carr, of Canandaigua, N. Y., in an 
article published in the American Journal of Medical 
Sciences, in October, 1842. 1 Expansion of the lungs 
of the sheep or calf, after removal from the body, 
the stethoscope being applied to the lung-surface, 
gives, in certain situations, a well-marked crepitant rale. 

1 Vide article by the author in the New York Monthly Med. 
Jour, for February, 1869. 



VESICULAR OR CREPITANT RALE 145 

The crepitant rale is a common sign in pneumonia. 
It very rarely occurs in any other pathological con- 
nection. Of all respiratory signs, this is most entitled 
to be called pathognomonic. It belongs especially to 
the" first stage of acute pneumonia. It is not invari- 
ably present, but it occurs in the majority of cases 
of acute pneumonia. In the second stage, or the 
stage of solidification, the rale generally disappears. 
It not infrequently is reproduced in the stage of reso- 
lution, and it is then called the returning crepitant 
rale. In the latter stage it is often found in combina- 
tion with the subcrepitant rale. The practical 
value of this sign relates chiefly to the diagnosis of 
pneumonia. 

It is stated that the crepitant rale is sometimes 
found in cases of pulmonary edema, and during or 
directly after an attack of hemoptysis. If it ever 
occur in these cases, the instances must be extremely 
rare. The statement is perhaps based on the occur- 
rence of the subcrepitant, this being confounded 
with the crepitant rale. It occurs transiently under 
the following circumstances: A patient who has 
been confined for some time in bed, lying on the back, 
and much enfeebled with any disease, if suddenly 
raised to a sitting posture and auscultated, a crepitant 
rale is often found on the posterior aspect of the chest 
at the end of a forced inspiration. The rale disappears 
after a few forced inspirations. It is heard, not on 
one side only, but on both sides. The explanation 
is, that during the recumbent posture continued for 
some time, and the patient breathing feebly, enough 
10 



146 AUSCULTATION IN DISEASE 

of the air-vesicles and bronchioles become agglutinated 
by means of a little sticky transudation to give rise to 
crackling sounds in a few forced inspirations. It may 
be of use to mention that if the stethoscope be applied 
to the anterior surface of a chest much covered with 
hair, the movements of the pectoral extremity of the 
instrument in the act of inspiration may produce a 
sound identical with the crepitant rale. This can be 
eliminated by applying oil or vaseline liberally over 
the hairy surface. 

A crepitant rale at the summit of the chest, within 
a circumscribed space, is one of the accessory signs 
of phthisis. It denotes a circumscribed pneumonia 
which clinical experience shows to be generally sec- 
ondary to phthisis; hence the diagnostic significance 
of the sign. 

CAVERNOUS OR GURGLING RALE 

A pulmonary cavity of considerable size, contain- 
ing a certain quantity of liquid, and communicating 
freely with bronchial tubes, furnishes a rale which 
is characteristic. The character of the sound is ex- 
pressed as fully as possible by the term gurgling. The 
sound is produced by large bubbling and the agitation 
of the liquid within the cavity. It may be compared 
to the sound produced by the boiling of a liquid in 
a flask or large test-tube. The sound is sometimes 
high pitched and amphoric, but generally it is low in 
pitch. It is heard with more or less intensity within 
a circumscribed space, almost invariably at or near the 



FRIC T I ON -SO UNDS 147 

summit of the chest; but if intense, the sound is 
diffused, and it may be sometimes heard at a distance. 
Its diagnostic importance relates to the advanced stage 
of phthisis. The rale is heard chiefly or exclusively 
in the act of inspiration. It may be produced by 
the act of coughing sometimes with greater intensity 
than by respiration. 

PLEURAL RALES— FRICTION-SOUNDS— METALLIC 
TINKLING— SPLASHING 

The signs embraced under the name pleural rales 
are: (1) Sounds produced by the rubbing together 
of the pleural surfaces, and hence called friction- 
sounds. (2) Metallic tinkling. (3) Splashing or 
succussion sounds. 

Friction-Sounds. — Movements of the pleural sur- 
faces upon each other take place in inspiration and 
expiration; but in health these movements occasion 
no sound. Sounds are produced when the surfaces 
are covered with a recent fibrinous exudation which 
prevents the normal continuous, unobstructed move- 
ments, and when the surfaces are roughened with 
dense lymph or other morbid products. The sounds 
are generally interrupted, that is, two, three, or more 
sounds occur during the act of inspiration or expira- 
tion, or during both acts. The intensity of the sounds 
varies much in different cases. A slight grazing sound 
only may be heard, or, on the other hand, the sounds 
may be so loud as to be heard by the patient, and by 
others at a distance. The character of the sounds 



148 AUSCULTATION IN DISEASE 

is variable. The slight rubbing or grazing character 
may be imitated by placing over the ear the palmar 
surface of one hand, and moving over its dorsal sur- 
face slowly the pulpy portion of a finger of the other 
hand. In some instances, however, the rough character 
of the sounds is expressed by such terms as rasping, 
grating, and creaking. In these instances the sounds 
denote density of the morbid product which roughens 
the pleural surfaces. In connection with very rough 
sounds, vibration of the walls of the chest, or fremitus, 
is sometimes perceived by palpation. 

Aside from the character of the sounds as just 
stated, they are distinguished by their apparent near- 
ness to the ear; they seem sometimes to be produced 
upon the surface of the chest. They are sometimes 
intensified by firm pressure of the stethoscope upon 
the chest. After a little practical knowledge of these 
sounds they can hardly be confounded with any other 
rales. 

Pleuritic friction-sounds generally denote pleurisy. 
In cases of pleurisy with effusion, slight rubbing or 
grazing is sometimes heard before much liquid accu- 
mulates within the pleuritic cavity. The physical 
conditions, however, after the effusion has been 
removed, are much more favorable for the production 
of friction-sounds, and they are often now rough in 
character. They may be transient, or they may 
continue for a considerable period, their duration 
depending on the arrest of the movements of the 
pleural surfaces by means of either agglutination with 
lymph, or adhesion from the growth of areolar tissue. 



METALLIC TINKLING 149 

Pleuritic friction-sounds occur not infrequently in 
cases of pneumonia, denoting, in this connection, 
coexisting pleurisy. 

Slight rubbing or grazing at the summit of the 
chest is one of the accessory signs of phthisis. It 
denotes a circumscribed, dry pleurisy, which, as clinical 
experience shows, is generally secondary to phthisis, 
and hence the diagnostic significance of the sign. 

In the foregoing instances in which friction-sounds 
are stated to occur, their significance relates to pleurisy. 
In some rare instances the sounds are produced by 
miliary tubercles, or neoplastic nodules projecting 
beyond the plane of the visceral pleural surface, with- 
out pleuritic inflammation. 

Metallic Tinkling. — This is a vocal as well as a respi- 
ratory sign. It is also produced by acts of coughing, 
and sometimes by the act of deglutition. The name 
expresses the distinctive character of the sign. It 
consists in a series of tinkling sounds of a high-pitched, 
silvery, or metallic tone. The number of sounds 
varies from a single sound to two, three, or more 
sounds, during an act of either inspiration or expi- 
ration. This sign may be imitated in various ways 
by means of an India-rubber bag of considerable 
size. Forcing a liquid into the bag with Davidson's 
syringe, tapping the bag with the finger, or shaking 
it, will produce tinkling sounds. The best mode of 
artificial representation of the sign is to connect the 
bag with a flexible tube, the latter containing a few 
drops of liquid, and blowing into the tube so as to 
produce bubbles at the communication of the tube 



150 AUSCULTATION IN DISEASE 

with the bag. In this latter experiment it is not 
necessary that the bag contain any liquid. It occurs 
irregularly, that is, it is not present in every act of 
breathing, but is heard at variable intervals. It may 
sometimes be produced by forced, when it is not heard 
in tranquil, breathing. It can only be confounded 
with tinkling sounds sometimes produced within 
the stomach. The latter, however, are easily dis- 
criminated by their situation, and the absence of 
associated signs denoting the affections of the chest 
in which the sign occurs. 

Metallic tinkling is the sign of pneumothorax with 
perforation of lung. In the great majority of the cases 
in which it is found, it is diagnostic of this affection. 
It is, however, always associated with other physical 
signs corroborative of the diagnosis. 

It is a rare sign, in cases of phthisis, of a large 
pulmonary cavity, the conditions for its production 
being analogous to those in pneumo-hydrothorax, 
namely, a space of considerable size containing air, 
the space communicating with bronchial tubes. 

Splashing, or Succussion Sounds. — This sign is pro- 
duced by succussion, which is reckoned as one of 
the different modes of physical exploration. Sounds 
thus produced are not infrequently heard at some 
distance; generally, however, succussion is practised 
while the ear is applied to the chest, so that properly 
enough the sign may be embraced among the aus- 
cultatory signs, although not produced by respiration. 

Splashing is pathognomonic of either pneumo- 
hydrothorax or pneumo-pyothorax. It is especially 



INDETERMINATE RALES 151 

valuable as a sign of these affections because it is 
almost invariably available. The instances are ex~ 
tremely few in which the sign is wanting when air 
and liquid are contained in the pleural cavity. It 
is obtained by jerking the body of the patient with 
a quick, somewhat forcible movement, the ear being 
very near to, or in contact with, the chest. 

The sound is like that produced when a bottle 
partially filled with liquid is shaken. The sound is 
often high-pitched and amphoric in quality. The 
only liability to error is in confounding with this 
sign, splashing produced within the stomach. Atten- 
tion to other signs will always protect against this 
error. 

Indeterminate Rales. — Under this head may be em- 
braced some sounds sufficiently recognizable, but 
indeterminate as regards the rationale of their pro- 
duction and the physical conditions which they rep- 
resent. They may be designated crumpling and 
crackling sounds. The former are probably due to 
pleuritic rubbing, and the latter to the separation 
of some slightly adherent air-vesicles or bronchioles. 
Their diagnostic value relates only to the early stage 
of phthisis. In conjunction with other signs, any 
indeterminate rale, if limited to the summit of the 
chest, and especially to one side, has some weight in 
the diagnosis. Crumpling and crackling sounds, 
however, are not uncommon in healthy persons at 
the end of forced inspiration. The fact of their pres- 
ence at both summits, and the absence of other morbid 
signs, are the grounds for not considering them as 



152 AUSCULTATION IN DISEASE 

evidence of disease. They are found in health, espe- 
cially if the binaural stethoscope be employed. Their 
diagnostic significance, thus, depends on limitation 
to the summit of the chest on one side, and associa- 
tion with other signs pointing to incipient phthisis. 

THE VOCAL SIGNS OF DISEASE 

The vocal signs of disease, with the exception of 
metallic tinkling, which is a vocal as well as respira- 
tory sign, may all be considered as abnormal modi- 
fications of the normal vocal resonance and of the 
normal bronchial whisper. The student must, there- 
fore, be familiar with the distinctive characters of 
these two normal signs before he is prepared to enter 
upon the study of the abnormal modifications (vide 
pages 99 and 105). We must bear in mind the facts 
which have been presented in relation to the normal 
vocal fremitus (vide page 100). The rules given for 
auscultation of the voice are also to be observed 
(vide page 89). Embracing the abormal modifica- 
tions of the loud voice, the whisper and fremitus, the 
following are the signs to be considered: Broncho- 
phony; Whispering Bronchophony; Egophony; In- 
creased Vocal Resonance; Increased Bronchial Whisper; 
Cavernous Whisper; Pectoriloquy; Amphoric Voice 
or Echo; Diminished and Suppressed Vocal Reso- 
nance; Diminished and Suppressed Vocal Fremitus, 
and Metallic Tinkling. 



BRONCHOPHONY 



BRONCHOPHONY 



Bronchophony has the same import as bronchial 
or tubular respiration. Like the latter sign, it rep- 
resents complete or considerable solidification of 
lung. Generally the two signs are associated, but 
either may be present without the other. 

The characters which are distinctive of broncho- 
phony, as compared with normal vocal resonance, 
are these: The vocal sound seems concentrated, in 
most cases near the ear, and the pitch is more or less 
raised. These characters are in contrast with the 
diffusion, distance, and lowness of pitch of the normal 
vocal resonance. The intensity of the sound is var- 
iable; it may be greater or less than the intensity 
of the normal resonance. A concentrated, high- 
pitched sound, however feeble, is not less a sign of 
complete or considerable solidification of lung, that 
is, it is not less bronchophony, than when the sound 
is intense. 

Vocal fremitus is always to be discriminated from 
vocal resonance. The fremitus associated with bron- 
chophony may, or may not, be greater than the 
fremitus of health. Not infrequently the fremitus is 
less than in health. 

It is to be borne in mind that in some healthy per- 
sons bronchophony exists at the summit of the chest, 
especially on the right side, over the primary bronchus. 
Existing in this situation, it may not be abnormal. 

Representing complete or considerable solidifica- 



154 AUSCULTATION IN DISEASE 

tion of lung, this sign occurs in the different affec- 
tions in which bronchial or tubular respiration has 
been seen to occur (vide page US), namely, lobar 
pneumonia, phthisis, chronic or fibroid pneumonia, 
condensation of lung from either pleuritic effusion, 
the accumulation of air in the pleural cavity or the 
pressure of a tumor, collapse of pulmonary lobules, 
coagulation of blood within the air-vesicles, and neo- 
plasm of lung. 

For the production of bronchophony, a less degree 
of solidification is requisite than for the production of 
bronchial or tubular respiration. Hence, broncho- 
phony may be associated with a broncho-vesicular, 
as well as with a purely bronchial, respiration. This 
is illustrated in the resolving stage of pneumonia. 
When resolution has progressed sufficiently for the 
bronchial to give place to the broncho-vesicular 
respiration, well-marked bronchophony is often found 
to continue, ceasing at a later period in the resolving 
stage. 

The apparent nearness to the ear of the vocal sound 
in bronchophony is wanting if a certain quantity of 
liquid intervene between the solidified lung and the 
walls of the chest at the situation auscultated. The 
voice under these conditions seems to be more or less 
distant. This difference is readily appreciated. With 
this apparent distance of the bronchophonic voice in 
some instances is associated the modification which is 
characteristic of another sign — namely, egophony. 



EGOPHONY 155 



WHISPERING BRONCHOPHONY 

The characters of this sign correspond to those of 
the expiratory sound in the bronchial or tubular res- 
piration {vide page 117). The sound is more or less 
intensified, high in pitch, and tubular in quality. 
If the patient pronounce numerals in a forced whis er, 
the characters are generally more marked than in 
the expiratory sound in forced breathing. The signifi- 
cance of this sign is the same as that of the bronchial 
or tubular respiration, and of bronchophony with the 
loud voice. 

EGOPHONY 

This sign is a modification of bronchophony. As 
regards concentration and pitch, it has the characters 
of bronchophony, the distinctive features being, ap- 
parent distance from the ear, the tremulousness or a 
bleating tone. From the latter the name is derived, 
the term signifying the cry of the goat. The characters 
which distinguish the sign from bronchophony are 
readily enough appreciated, and it represents a phy- 
sical condition added to solidification of lung. This 
physical condition is the presence of liquid effusion. 
The sign is rarely present in cases of large effusion. 
It occurs usually when the chest is about half filled 
with liquid, and the lung at the level of the liquid is 
sufficiently condensed to give rise to bronchophony. 
This condition, under these circumstances, involve 
agglutination of lung above the portion condensed 



156 AUSCULTATION IN DISEASE 

by pressure. The sign also sometimes occurs in cases 
of pleuro-pneumonia, the solidification in these cases 
being due to pneumonic exudation. As a sign of 
liquid effusion it possesses diagnostic value, although, 
owing to the fact that the existence of effusion is 
easily determined by other signs, it may be said to be 
superfluous. When the person examined speaks with 
the teeth approximated, bronchophony has somewhat 
of the character of egophony. 



INCREASED VOCAL RESONANCE AND 
FREMITUS 

The distinctive character of this sign is an increase 
of the intensity of the resonance without notable 
change in other respects. The resonance may be 
more or less intensified, but it is distant, diffused, 
and comparatively low in pitch; in other words, the 
characters distinctive of bronchophony are wanting. 
The differential points between bronchophony and 
increased resonance should be clearly apprehended, 
bearing in mind that the intensity of the sound in 
bronchophony may* or may not, be greater than the 
normal resonance. 

Increased vocal resonance occurs when the lung 
is solidified, the solidification not sufficient in degree 
to produce bronchophony. Lung slightly or mod- 
erately solidified gives rise to an increase of the inten- 
sity of the resonance of the voice; if the solidification 
become considerable or complete, bronchophony takes 
the place of the simple increase of intensity. Thus, 



VOCAL RESONANCE AND FREMITUS 157 

at an early period in pneumonia, increased vocal 
resonance precedes bronchophony; and in the stage 
of resolution the reverse of this takes place — namely, 
increased vocal resonance follows bronchophony, the 
latter ceasing when resolution has progressed to a 
certain extent. 

Contrary to what would perhaps be anticipated in 
the instances just cited, the intensity of the sound 
when bronchophony is present may be not only not 
increased, but diminished below that of health; that 
is, in the first stage of pneumonia the increased inten- 
sity may cease when bronchophony occurs, and return 
when bronchophony disappears. 

Increase of the vocal resonance occurs in connec- 
tion with pulmonary cavities. Over a cavity of con- 
siderable size, situated near the superficies of the lung, 
the vocal resonance is sometimes extremely intense, 
without any bronchophonic characters. The latter, 
if present, denote considerable solidification either 
around the cavity, or between it and the walls of the 
chest. From the presence or the absence of bron- 
chophonic characters with greatly increased intensity 
of resonance, the auscultator can judge whether the 
cavity be, or be not, in proximity to considerable 
solidification of lung. 

Irrespective of the cavernous stage of phthisis, the 
sign is of diagnostic importance in the different affec- 
tions which involve moderate or slight solidification of 
lung — namely, pneumonia early in the disease and in 
the stage of resolution, phthisis, over the compressed 
lung in pleurisy with moderate effusion, collapse of 



158 AUSCULTATION IN DISEASE 

pulmonary lobules, hemorrhagic infarctus, and neo- 
plasms of lung. Into the diagnosis of all these affec- 
tions, both bronchophony and increased vocal reso- 
nance enter; the former when solidification is consid- 
erable or complete, and the latter when it is slight 
or moderate. Increased vocal resonance is especially 
valuable in the diagnosis of early or incipient phthisis. 
An abnormal resonance, however slight, at the summit 
of the chest on one side, is an important sign in that 
affection. In determining an abnormal resonance 
on the right side, either of the summit or elsewhere, 
allowance must always be made for the normally 
greater resonance on this side. 

Increased vocal resonance has the same import as 
broncho-vesicular respiration. These two signs, how- 
ever, are not always in the same proportion; that is, 
the characters of the latter may be marked, out of 
proportion to the amount of the increase of the vocal 
resonance, and vice versa. 

Increased vocal fremitus generally accompanies 
increased vocal resonance, and it denotes solidifica- 
tion of lung. Fremitus, however, and resonance are 
not always in equal proportion, that is, either may 
be increased more than the other. An increased 
fremitus is sometimes of value in the diagnosis of 
phthisis. The greater fremitus on the right side of the 
chest is always to be borne in mind, and due allow- 
ance is to be made for this disparity in determining 
that the fremitus is increased. 



INCREASED BRONCHIAL WHISPER " 159 



INCREASED BRONCHIAL WHISPER 

The significance of this sign is the same as that of 
increased vocal resonance and the broncho-vesicular 
respiration; it represents the same physical condition 
as the two latter signs — namely, solidification of lung, 
greater or less, but below the degree requisite to give 
rise to bronchophony and bronchial respiration. Its 
diagnostic application is, therefore, involved in the 
same pulmonary affections. 

The characters of the sign are those which belong 
to the expiratory sound in the broncho-vesicular 
respiration. They consist, therefore, of increase of 
intensity, a quality more or less tubular, and the 
pitch raised, these modifications of the normal expi- 
ratory sound varying in degree, between the slightest 
appreciable morbid change, and a close approximation 
to the bronchophonic whisper. The modifications 
in degree correspond to the degree of solidification. 
To appreciate the characters of this sign, it must be 
studied in comparison with those of the normal bron- 
chial whisper in different portions of the chest. The 
most important of the diagnostic applications of the 
sign is in cases of phthisis in its early stage. In this 
application, the points of normal disparity between 
the two sides of the chest at the summit are to be 
borne in mind, and due allowance made for them 
{vide page 107). 

A greater intensity of the bronchial whisper at the 
right than at the left summit is not evidence of dis- 



160 AUSCULTATION IN DISEASE 

ease; but greater intensity at the left summit is always 
abnormal. As a rule, the pitch of the normal bron- 
chial whisper at the left is higher than that at the right 
summit; if, therefore, with a greater intensity of the 
whisper at the right summit it be a matter of doubt 
whether .it denote diseases or not, when the pitch is 
higher at this summit it is to be considered as morbid. 

Cavernous Whisper. — The characters distinctive of 
the cavernous whisper are those of the expiratory 
sound in the cavernous respiration — namely, lowness 
of pitch, and the quality blowing, that is, non-tubular. 
The intensity of the sound is variable. It is limited 
to a circumscribed space corresponding to the situa- 
tion and size of the cavity. Not infrequently the 
characters of the sign are brought into contrast 
with those of whispering bronchophony, or increased 
bronchial whisper, these latter signs existing in close 
proximity, and representing solidification of lung in 
the immediate neighborhood of the cavity. The diag- 
nostic application of this sign is chiefly to advanced 
phthisis. 

Pectoriloquy. — In pectoriloquy, not merely the voice, 
but the speech, is transmitted through the chest; the 
auscultator recognizes words uttered by the patient. 

The student, however, must not expect to be able 
to carry on a conversation with the patient by means 
of the stethoscope. Often single words only can be 
recognized. To make sure that these are transmitted 
through the chest, care must be taken to exclude 
their direct transmission from the patient's mouth, 
and the auscultator should not know T beforehand the 



INCREASED BRONCHIAL WHISPER 161 

words which are to be spoken. If these rules be not 
observed, the auscultator may err in supposing that 
the words are transmitted through the chest. When 
auscultation is practised with one ear, the other should 
be closed. 

The speech with either the loud or the whispered 
voice may be transmitted, the latter, distinguished 
as whispering pectoriloquy, being much more fre- 
quent than the former; moreover, in determining 
whispering pectoriloquy, there is less liability to 
error in mistaking the perception of w r ords coming 
directly from the mouth for the transmission through 
the chest. In the production of this sign much depends 
on the distinctness with which words are articulated 
by the patient. Normal pectoriloquy at the anterior 
superior portion of the chest is sometimes observed. 

Pectoriloquy belongs among the cavernous signs; 
but it is by no means exclusively the sign of a cavity; 
the speech may also be transmitted by solidified lung. 
It is easy to determine in any case whether the sign 
denotes a cavity or solidified lung. If, with trans- 
mitted speech, the voice have the characters of bron- 
chophony, the sign represents solidification of lung; 
if, on the other hand, the characters of bronchophony 
be wanting, the sign represents a cavity. 

These statements apply equally to the loud and 
to the whispered voice. Of course, associated signs 
will be likely to show w T hether a cavity exists or not. 
It is to be added that a cavity and solidification of 
lung, existing together, may conjointly be concerned 
in the production of the sign. 
11 



162 AUSCULTATION IN DISEASE 

Amphoric Voice or Echo. — This sign is identical in 
character with amphoric respiration, with which it 
is usually associated (vide page 127). The amphoric 
intonation may accompany the loud voice and the 
whisper; generally, it is more appreciable or marked 
with the latter. Its significance is the same as that 
of amphoric respiration. As a rule, it represents 
the conditions in pneumothorax — namely, a large 
space filled with air and perforation of lung. In this 
affection it is associated with other signs which suffice 
for a prompt and positive diagnosis. It is not inva- 
riably found in pneumothorax, and it may be present 
in a case at one time and wanting another time; 
its production being dependent on the perforation 
being above the level of liquid, if the latter exist, 
and on the bronchial tubes leading to the perfora- 
tion being unobstructed. When not associated with 
other signs which are diagnostic of pneumothorax, 
it denotes a phthisical cavity of considerable size. 
It is not infrequently a sign of a phthisical cavity 
with rigid walls and communicating freely with bron- 
chial tubes. It has this significance whenever pneumo- 
thorax can be excluded; and the associated signs in 
the latter affections are such that its exclusion is always 
practicable. 

The amphoric sound sometimes is observed to 
follow the oral voice; hence, the name amphoric echo. 

Diminished and Suppressed Vocal Resonance. — Dimi- 
nution and suppression of the normal vocal resonance 
occur especially when the pleural cavity contains 
either liquid or air. Whenever the lungs are not 



INCREASED BRONCHIAL WHISPER 163 

in contact with the walls of the chest, the vocal reso- 
nance, as a rule, is either notably lessened or wanting. 
The sign is, therefore, of value in diagnosis in cases 
of pleurisy with effusion, empyema, hydrothorax, 
and pneumothorax. When the pleural cavity is parti- 
ally filled with liquid, there is diminution or suppres- 
sion of the resonance from the level of the liquid down- 
ward; and generally, just above the level of the liquid, 
the resonance is increased, owing to condensation of 
the lung. The sign is well illustrated by the con- 
trast in such cases above and below the level of the 
liquid. As a rule, the changes of the level of the 
liquid with changes in position of the body may be 
as well demonstrated by means of vocal resonance as 
by percussion. Exceptionally, however, this rule is 
not available. 

The practical importance of diminished, and sup- 
pressed, vocal resonance relates chiefly to the diag- 
nosis of the affections just named. In this application, 
however, the associated signs must be taken into 
account. The vocal resonance may be diminished, 
or suppressed, when the lung is completely solidified 
in the second stage of pneumonia, when the consolida- 
tion involves the bronchi resulting in their obstruction; 
also in pulmonary edema, and over the site of an intra- 
thoracic tumor. 

If the vocal resonance be normal, that is, neither 
increased nor diminished, we are warranted in exclud- 
ing all the affections which have been named; the 
exceptional instances are so rare that, practically, 
they may be disregarded. 



164 AUSCULTATION IN DISEASE 

Diminished vocal resonance may be found over a 
pulmonary abscess before the pus is evacuated, and 
over a cavity filled with liquid. The sign is then 
limited to a circumscribed space. Obstruction of a 
bronchial tube diminishes resonance in so far as the 
column of air is a medium for the conduction of vocal 
sound. 

In emphysema and in chronic pleurisy with marked 
thickening of the parietal or visceral pleura, or of both, 
due to organized fibrin and connective tissue, we find 
marked instances of diminished and suppressed vocal 
resonance. 

The normal disparity between the two sides of the 
chest is to be borne in mind with reference to dim- 
inished or suppressed, as well as to increased, vocal 
resonance; otherwise the relative feebleness of the 
resonance on the left side in health might be con- 
sidered to be morbid. The normally greater reso- 
nance on the right side renders it easier to determine 
a morbid diminution on this than on the left side. 

If the stethoscope be firmly pressed upon the lower 
part of the chest wall, especially in front, above the 
lower border of the lung there may be a great sup- 
pression or even total absence of vocal resonance. 
The vibration of the chest wall, particularly in the 
lower part, is easily interfered with by a too firm 
pressure of the stethoscope bell upon the chest. 

Diminished and Suppressed Vocal Fremitus. — This 
tactile sensation, which is appreciable in ausculta- 
tion, as a rule, is, on the one hand, increased, and, 
on the other hand, diminished or suppressed, under 



INCREASED BRONCHIAL WHISPER 165 

the same physical conditions which occasion corre- 
sponding modifications of the vocal resonance. Dim- 
inished or suppressed vocal fremitus, therefore, has 
the same diagnostic significance as diminished or 
suppressed vocal resonance. Usually the abnormal 
modifications of resonance and fremitus go together 
but either may be out of proportion to the other. 
The signs relating to fremitus thus corroborate those 
relating to resonance. The former may be marked 
when the latter admit of doubt. Diminished or 
suppressed fremitus is valuable in the diagnosis of 
pleurisy with effusion, empyema, hydrothorax, pneu- 
mothorax, emphysema, and chronic thickened pleura. 
It is, however, to be noted that in exceptional 
instances the fremitus persists over the site of liquid 
within the chest. 

With regard to vocal fremitus, as to vocal reso- 
nance, it is essenital to take cognizance of the normal 
disparity between the two sides of the chest, the greater 
relative fremitus, on the right side, as a rule, being no 
less marked than the relatively greater resonance on 
that side. 

Metallic Tinkling. — This sign has the same char- 
acters when it accompanies either the loud or whis- 
pered voice, as when it is heard with respiration, 
and, of course, it has the same significance (vide page 
149). It may be more marked with acts of speaking 
than with the respiratory acts. 



166 AUSCULTATION IN DISEASE 



SIGNS OBTAINED BY ACTS OF COUGHING 
OR TUSSIVE SIGNS 

Acts of coughing may be made subservient to 
auscultation of respiratory sounds in two ways: (1) 
By the removal of temporary obstruction from the 
accumulation of mucus within bronchial tubes. If 
the respiratory murmur be diminished or suppressed 
over a portion or the whole of one side of the chest, 
sometimes an act of coughing effects dislodgement 
of a mass of mucus from either a primary bronchus 
or one of its subdivisions, and the normal murmur 
is at once restored. The dependence of the morbid 
sign upon a temporary obstruction is thus demon- 
strated. (2) By an act of coughing more air is 
expelled than by an ordinary expiration, and in the 
following inspiration the vesicles have a wider range 
of expansion, giving rise to a proportionately loud 
inspiratory sound; hence, the characters of this sound 
are pronounced and can be better studied. For these 
two objects it is often advisable to request the patient 
to cough with a certain degree of force. 
. This procedure, of having the patient cough at the 
end of an expiratory act, and immediately breathe in 
freely, is of particular advantage in eliciting the elusive 
fine crepitations at the apices of the upper or lower 
lobes in suspected or early pulmonary tuberculosis. 

Acts of coughing, moreover, give rise to ausculta- 
tory signs which have their analogues in signs obtained 
by respiration and the voice. These tussive signs 



ACTS OF COUGHING OR TUSSIVE SIGNS 167 

are of less value than the respiratory and vocal signs, 
and in most cases, owing to the latter being sufficient 
for diagnosis, they may be said to be superfluous; 
nevertheless, they may be observed sometimes with 
advantage. When the conditions are present which 
are represented by bronchial respiration, bronchophony 
and the bronchophonic whisper, sounds are obtained 
which correspond to these in their characters. The 
cough is then said to be bronchial. With the steth- 
oscope applied over an empty cavity of some size, 
situated near the surface of the lung, the ear receives 
with acts of coughing a concussion or shock which is 
sometimes so forcible as to be painful. This corre- 
sponds to an intense vocal resonance. Limited to a 
circumscribed space, it is a highly significant cavernous 
sign. It may be present when the cavernous respira- 
tion is wanting. A low-pitched blowing sound corre- 
sponds to the expiratory sound in the cavernous respi- 
ration and the cavernous whisper. An amphoric 
intonation may be heard with acts of coughing, which 
corresponds to amphoric respiration and amphoric 
voice. This sign is sometimes more marked with cough 
than with the breathing and voice. Cavernous gurg- 
ling may also be obtained more distinctly with cough 
than with respiration. Finally, metallic tinkling not 
infrequently accompanies acts of coughing. 



CHAPTER VI 

THE PHYSICAL DIAGNOSIS OF DISEASES OF 
THE RESPIRATORY ORGANS 

Affections of the larynx and trachea — Bronchitis seated in 
large bronchial tubes — Bronchitis seated in small bronchial tubes, 
or capillary bronchitis — Collapse of pulmonary lobules — Lobular 
pneumonia — Asthma — Pulmonary or vesicular emphysema — 
Pleurisy, acute and chronic — Empyema — Hydrothorax — Pneu- 
mothorax — Pneumo-hy drot hor ax — Pneumo-py o thorax — Acute 
lobar pneumonia — Circumscribed pneumonia — Embolic pneu- 
monia — Hemorrhagic infarctus — Pulmonary apoplexy — Pul- 
monary gangrene — Pulmonary edema — Neoplasms of lung — 
Tumor within the chest — Acute miliary tuberculosis — Pul- 
monary phthisis — Fibroid phthisis, interstitial pneumonia, or 
cirrhosis of lung — Diaphragmatic hernia. 

In the preceding chapters the physical conditions 
incident to the morbid changes occurring in the affec- 
tions of the respiratory organs have been enumerated, 
and the physical signs, obtained by percussion and 
auscultation, representing these conditions, have been 
considered, severally, as regards their distinctive 
characters and their significance. The object of this 
chapter is to group the physical conditions embraced 
in the different diseases of the respiratory system 
respectively, together with the representative signs 
on which rests the physical diagnosis of each of the 
diseases. The scope of this manual is limited to the 
physical diagnosis of these affections; but the fact is 



AFFECTIONS OF LARYNX AND TRACHEA 169 

not to be lost sight of that in practical medicine phy- 
sical signs are not to be disassociated from symptoms 
and pathological laws. An exclusive reliance on phy- 
sical signs would lead to errors in diagnosis, although, 
doubtless, errors more important and more frequent 
necessarily occur when the practitioner ignores per- 
cussion and auscultation. The signs furnished by 
percussion and auscultation only have been thus far 
considered, but in grouping these in this chapter, 
signs obtained by other methods of physical explora- 
tion will be embraced in so far as they enter into the 
diagnosis of the different diseases of the respiratory 
system. These different diseases will be taken up 
separately with the exception of those seated in the 
larynx and trachea. With reference to physical signs, 
the laryngeal and tracheal affections may be consid- 
ered collectively. 

AFFECTIONS OF THE LARYNX AND TRACHEA 

The physical signs referable to the chest in dis- 
eases of the larynx and trachea, denote more or less 
obstruction to the free passage of air through these 
sections of the air-tubes. The obstruction in the 
different diseases involves different pathological con- 
ditions. Spasm of the glottis is one of these conditions, 
constituting the affections known as laryngismus 
stridulus and spasmodic croup, occurring also as a 
pathological element in laryngitis, and sometimes in 
connection with aneurism, or a tumor of some kind, 
involving the recurrent laryngeal nerve. Another 



170 DISEASES OF THE RESPIRATORY ORGANS 

pathological condition is the opposite of this, namely, 
paralysis of the muscles of the glottis, the vocal chords 
remaining flaccid, and approximating during inspira- 
tion. Other pathological conditions are, edema of 
the glottis, swelling of the membrane at the glottis 
in laryngitis, together with, in the adult, submucous 
infiltration, diphtheritic exudation, cicatrization of 
ulcers, morbid growths, and the presence of foreign 
bodies. 

In the affections involving the foregoing patho- 
logical conditions, percussion and auscultation are of 
use: (1) By enabling the physician to exclude all 
diseases within the chest. The absence of signs show- 
ing the existence of pulmonary diseases renders it 
certain that the symptoms denoting embarrassment 
of respiration are referable to the larynx or trachea. 
(2) By means of auscultation the amount of obstruc- 
tion may be determined more accurately than by the 
subjective symptoms. The amount of obstruction is 
represented by a proportionate weakening of the vesic- 
ular murmur. This is more reliable as regards deter- 
mining a dangerous amount of obstruction than the 
sense of the want of air or the suffering of the patient. 
The degree of diminution of the vesicular murmur is 
determinable with the more accuracy, the better the 
auscultator is acquainted with the normal intensity, 
that is, the intensity prior to the occurrence of obstruc- 
tion. With this knowledge, the weakening of the 
murmur is a correct criterion of the amount of obstruc- 
tion. In all the pathological conditions named, the 
respiratory murmur is more or less diminished in 



AFFECTIONS OF LARYNX AND TRACHEA 171 

intensity on both sides of the chest; there are no signs 
obtained by percussion, nor do vocal resonance or 
fremitus offer anything distinctive. 

In cases of considerable or great obstruction during 
inspiration, inspection furnishes marked signs. The 
expansion of the chest on both sides is restricted, 
the lower part of the chest is contracted in the act 
of inspiration, and in this act the soft parts above 
the clavicles are depressed. The contrast between 
these abnormal movements and the normal thoracic 
movements of the patient is striking and distinctive. 

An important application of auscultation is the 
localization of a foreign body which has been inhaled. 
If the vesicular murmur on both sides be more or less 
weakened, the foreign body must be situated in either 
the larynx or the trachea. If, on the other hand, 
the vesicular murmur be weakened or suppressed on 
one side, and increased on the other side, the body 
is lodged in a primary bronchus. The importance 
of this application of auscultation before opening 
the trachea to remove a foreign body is sufficiently 
obvious. The situation of a foreign body may be 
changed from one bronchus to the other by an act of 
coughing, even after an operation has been commenced ; 
this is, of course, at once determinable by auscultation. 

By the application of x-ray examination, especially 
when combined with stereoscopic study of the plates, 
invaluable information is to be obtained as to the 
location of foreign bodies within the air-passages. 
When available it should be used to supplement 
auscultation and percussion. 



172 DISEASES OF THE RESPIRATORY ORGANS 



BRONCHITIS SEATED IN LARGE BRONCHIAL 
TUBES 

In bronchitis, either acute or chronic, as it is or- 
dinarily presented in practice, the inflammation is 
seated in the large bronchial tubes, in many cases 
probably not extending beyond the primary and 
secondary bronchi. The physical conditions are, 
more or less swelling of the mucous membrane, this, 
however, not being sufficient to occasion any notable 
obstruction to the free passage of air, and the pres- 
ence, in different cases, in greater or less quantity, of 
mucus, muco-purulent matter, pure pus, and serum. 

The physical diagnosis involves negative rather 
than positive points; in other words, the diseases 
from which bronchitis is to be differentiated are ex- 
cluded by the absence of their diagnostic signs. These 
diseases are pneumonia, pleurisy, and phthisis. Each 
of these is characterized by the presence of signs, 
the absence of which warrants its exclusion. In 
bronchitis there is no disparity between the two sides 
of the chest in the resonance obtained by percussion, 
nor in vocal resonance, the bronchial whisper, and 
fremitus. The swelling of the bronchial mucous 
membrane may cause some diminution of the intensity 
of the vesicular murmur, but as the affection is bilat- 
eral, and the bronchial tubes on each side are affected 
equally, both in degree and extent, no appreciable 
disparity in this respect between the two sides is 
caused by this physical condition. Weakening or 



BRONCHITIS IN LARGE BRONCHIAL TUBES 173 

suppression of the murmur over an area greater or 
less, may be caused by bronchial obstruction from a 
plug of mucus. This obstruction is sometimes removed 
by an act of expectoration, after which the murmur 
is. found to have returned, or to have regained its 
normal intensity. 

The foregoing points, taken in connection with 
the history and symptoms, suffice for the diagnosis. 
Signs due directly to the disease represent diminished 
calibre of the tubes at certain points from swelling 
of the membrane, adhesive mucus, and spasm of bron- 
chial muscular fibres. These signs are the dry bron- 
chial rales. They are rarely prominent, and are oftener 
absent than present, if the bronchitis be unaccompanied 
by asthma; hence, they are of little value in the diag- 
nosis. Other signs are the bubbling sounds or the 
moist bronchial rales. In acute bronchitis these are 
oftener absent than present. They occur when liquid 
morbid products within the tubes are unusually abun- 
dant, or when the removal of these is with difficulty 
effected by expectoration in consequence of muscular 
debility or other causes. These rales are abundant 
and loud in proportion as the liquid within the tubes 
is either muco-purulent, purulent, or serous in char- 
acter. They are more or less coarse in proportion to 
the size of the tubes in which the bubbling takes place. 

The diagnostic points, negative and positive, which 
have been stated, are alike applicable to acute and 
chronic bronchitis, it being, of course, understood 
that the affection is primary, that is, not secondary 
to some other pulmonary disease. 



174 DISEASES OF THE RESPIRATORY ORGANS 

If the bronchitis be unaccompained by solidification 
of lung, the moist rales which may be present are 
low in pitch. The pitch is raised if there be solidified 
lung surrounding or adjacent to the tubes in which 
the moist rales are produced. 

BRONCHITIS SEATED IN SMALL BRONCHIAL TUBES 

—CAPILLARY BRONCHITIS— COLLAPSE OF 

PULMONARY LOBULES— LOBULAR 

PNEUMONIA 

Inflammation extending into the small tubes (cap- 
illary bronchitis) occasions in these the same physical 
. conditions which are incident to bronchitis affecting 
tubes of large size, namely, swelling of the membrane, 
and the presence of liquid morbid products. The 
latter are not as easily removed by expectoration as 
when they are within large tubes, and, therefore, they 
are constantly present in greater or less quantity. 
These conditions in small tubes involve obstruction 
to the passage of air to and from the air-vesicles; 
hence, the vast difference as regards the symptoms, 
the suffering, and the danger. The affection is bilateral, 
a fact greatly enhancing the gravity of the affection. 
An incidental physical condition is solidification, 
generally in disseminated portions of lung, the latter 
varying in number and size. These portions of solid- 
ified lung denote either collapse of pulmonary lobules 
or lobular pneumonia, or both in conjunction. To 
this incidental affection, German writers apply the 
name " catarrhal pneumonia/' Of course, any dis- 
cussion of pathological questions suggested by these 



BRONCHITIS IN SMALL BRONCHIAL TUBES 175 

names would be here out of place. With reference 
to diagnosis it is to be borne in mind that the solidi- 
fied portions of lung in cases of bronchitis seated in 
small tubes are especially situated in the lower lobes. 
Another incidental physical condition is temporary 
dilatation of the air-cells, or vesicular emphysema, 
seated in the upper lobes. Both of these incidental 
conditions are bilateral, like the bronchitis with which 
they are connected. Collapse of pulmonary lobules, 
or lobular pneumonia, or both, and emphysema occur 
in only a certain proportion of the cases of bronchitis 
seated in small tubes. The signs, therefore, admit of 
a division into those which relate (1) to the bron- 
chitis, and (2) to these incidental affections. With 
reference to the diagnosis, the fact is to be borne in 
mind that bronchitis seated in small tubes occurs 
chiefly in children and the aged. 

The physical diagnosis of bronchitis seated in 
small tubes rests on negative points, together with 
a positive sign which is uniformly present. This 
sign is the fine moist bronchial or the so-called sub- 
crepitant rale, present on both sides and diffused 
over the chest. The bubbling sounds are to be dis- 
tinguished from the fine dry crackling sounds or the 
crepitant rale, to the characters of which the former 
in some measure approximate. 

The bronchitis gives rise neither to dulness on 
percussion, nor to any notable change in vocal reso- 
nance, or fremitus. The respiratory murmur, if not 
obscured by rales, is weakened on both sides. Irre- 
spective of being drowned by rales, it may be sup- 



176 DISEASES OF THE RESPIRATORY ORGANS 

pressed by the amount of bronchial obstruction. 
These are the negative points in the diagnosis. In 
pulmonary edema, fine moist bronchial rales are 
present on both sides, but in this affection there is 
notable dulness on percussion, and the affection occurs 
in certain pathological connections — namely, with 
mitral stenosis, and disease of the kidneys. Acute 
tuberculosis may present the moist bronchial rales 
with the negative points which, in connection with 
symptoms, characterize bronchitis seated in the small 
tubes. The differentiation is to be based on differences 
pertaining to the history and duration, together with 
the age of the patient. 

The coexistence of the incidental affections, namely, 
collapse of pulmonary lobules, or lobular pneumonia, 
and vicarious emphysema, occasions additional signs. 
If the solidified portions of lung be considerable in 
either number or size, there will be dulness on per- 
cussion in circumscribed situations on the posterior 
aspect of the chest. This will be found on both sides, 
but perhaps more marked on one side. Broncho- 
vesicular or the bronchial respiration may be present, 
together with the vocal signs of solidification, namely, 
either increased vocal resonance, or bronchophony, 
and increased vocal fremitus. The moist rales pro- 
duced within solidified portions of lung are high in 
pitch, wiiereas, if solidification do not exist, these rales 
are comparatively low in pitch. The existence of 
solidification at any point may be determined by the 
pitch of the rales, as well as by the foregoing respira- 
tory and vocal signs. 



ASTHMA 177 

When there are emphysematous lobules on the 
anterior aspect of the chest in the upper and middle 
regions, on both sides, the resonance on percussion 
is vesiculotympanitic, the respiratory murmur weak- 
ened or suppressed, and the rhythm altered — in short, 
the combination of signs which will be stated under 
the head of emphysema. 

In the cases in which the bronchitis occasions 
great obstruction in the small tubes, and, still more, 
if collapse of lobules, or lobular pneumonia and vicari- 
ous emphysema occur, important signs are obtained 
by inspection. The anterior portion of the chest 
remains expanded, and retraction of the lower part 
of the chest takes place in the acts of inspiration. 



ASTHMA 

The pathologico-physical condition in a paroxysm 
of asthma, is obstruction in the small bronchial tubes, 
attributable to spasm of the bronchial muscular fibres. 
With this condition is associated a temporary vesic- 
ular emphysema, which exists often as a persistent 
affection in persons who are subject to asthma. If 
the emphysematous condition already exist it is 
increased during the paroxysm of asthma. Bronchitis 
generally coexists, either as a transient or a chronic 
affection. In an asthmatic paroxysm, therefore, 
there are present the signs which are proper to asthma, 
together with those of emphysema, and the associated 
bronchitis may also occasion additional signs. 
12 



178 DISEASES OF THE RESPIRATORY ORGANS 

The physical diagnosis of asthma, like that of 
bronchitis seated in small tubes, is based on nega- 
tive points taken in connection with a sign which is 
invariably present, namely, dry bronchial rales. These 
rales are more or less intense, and they are diffused 
over the entire chest. They are generally heard at 
a distance. The sibilant and sonorous varieties are 
mingled, and they are constantly changing as regards 
the character of the sounds. 

The negative points are the same as in capillary 
bronchitis, namely, absence of dulness on percussion, 
vocal resonance and fremitus also being unaltered. 
Asthma and bronchitis seated in small tubes agree 
in the fact that obstruction is the important physical 
condition. A highly important differential point 
relates to the frequency of the respirations; they 
are much increased in frequency in capillary bron- 
chitis, and not in asthma. Pathologically they differ 
essentially in the fact that the obstruction is due in 
the latter affection to bronchial inflammation, and 
in the former to spasm. The two affections differ 
in the signs representing these different conditions — 
fine moist bronchial rales existing in one, and loud 
diffused dry bronchial rales existing in the other. 

Taking the difference, as regards the positive physical 
signs, in connection with the history and symptoms, 
the differentiation of the two affections may be made 
Without difficulty. 

The signs which relate to the associated emphy- 
sematous condition are those which are diagnostic 
of this condition, existing irrespective of asthma; 



PULMONARY OR VESICULAR EMPHYSEMA 179 

and the physical diagnosis of emphysema will be 
next considered. Coexisting bronchitis may give 
rise to moist bronchial rales more or less coarse. These 
are, however, often wanting, and they are rarely 
marked during paroxysms of asthma. When present 
in this pathological connection, they are low in pitch, 
denoting the absence of solidification of lung. 



PULMONARY OR VESICULAR EMPHYSEMA 

This affection, as a rule, is seated exclusively or 
chiefly in the upper lobes. When it is lobar, in con- 
tradistinction from the emphysema existing in com- 
paratively a few disseminated or isolated portions 
of lung, increase in volume of the affected lobes is an 
important physical condition standing in relation to 
certain signs. Diminished range of expansion with 
acts of inspiration is another physical condition; the 
affected lobes are in a permanent state of expansion 
approximating to that at the end of the inspiratory 
act. It follows from these conditions that the amount of 
air is in excess of the normal proportion to the solids 
and liquids in the affected lobes. Both lungs are 
affected, that is, the affection is bilateral. In the great 
majority of cases chronic bronchitis coexists, and 
patients affected with emphysema are often, but by 
no means invariably, subject to paroxysms of asthma. 
Not infrequently an asthmatic element, with or without 
pronounced paroxysms of asthma, exists much of 
the time in connection with emphysema. The emphy- 



180 DISEASES OF THE RESPIRATORY ORGANS 

sematous condition, as a rule, with few exceptions, 
is greater in the upper lobe of the left, than of the 
right lung. A rare condition, which is generally 
included under the name emphysema, differs mate- 
rially from the ordinary form of this affection. This 
condition is that also known as senile atrophy of the 
lungs. The volume of the lungs is not increased in 
this variety of emphysema, the proportion of air 
over the solids is, however, in excess, owing to the 
diminution of the latter from atrophy. 

The diagnostic evidence obtained by percussion is 
quite distinctive of lobar emphysema. The reso- 
nance over the upper and middle regions of the chest 
on both sides is vesiculo-tympanitic, that is, the 
intensity of the resonance is abnormally increased, the 
quality is a combination of the vesicular and tym- 
panitic, and the pitch is more or less raised. Owing 
to the fact that the emphysema is greater on the left 
than on the right side, the vesiculo-tympanitic reso- 
nance is more marked on the left side. The difference 
in intensity between the two sides may lead to the 
error of regarding the resonance on the right side as 
dulness. The error is avoided by attention to the 
pitch, and the quality of the resonance. If dulness 
existed on the right side, the pitch of the sound should 
be higher on that side; on the other hand, if the differ- 
ence in intensity be due to the greater amount of 
emphysema on the left side, the pitch is higher on 
that side, and the quality vesiculo-tympanitic. The 
attention of the student is particularly called to the fore- 
going points of distinction. Assuming that a vesiculo- 



PULMONARY OR VESICULAR EMPHYSEMA 181 

tympanitic resonance exists anteriorly on both sides, 
and that it is marked on the left as contrasted with 
the right side, how is the existence of this sign 
on the right side to be determined? The answer is, 
the resonance over the upper is to be compared with 
that over the lower lobe of the right lung. Percussing 
first over the upper lobe of the right lung, and second 
over the lower lobe of this lung, that is, posteriorly, 
below the scapula, or in the infra-axillary region, the 
vesiculotympanitic resonance over the upper lobe is 
rendered manifest. In a series of patients affected 
with emphysema, the uniformity of the results of 
percussion is very striking; anteriorly, over the left 
side, the resonance is vesiculotympanitic as com- 
pared with the resonance on the right side, and the 
resonance is shown to be vesiculotympanitic on the 
right side anteriorly, as compared with the resonance 
posteriorly below T the scapula. 

As regards the abnormal modifications of the respira- 
tory murmur in emphysema, there is (1) either weak- 
ened respiratory murmur without notable change 
in pitch or quality, or suppression of the murmur. 
Diminished intensity of the murmur exists over the 
upper lobes on both sides, as compared with the mur- 
mur over the lower lobes; and in most cases the greater 
diminution or the suppression is on the left rather 
than on the right side. Exceptions to the latter state- 
ment may be caused by obstruction of the bronchial 
tubes on the right, and not on the left side, by an 
accumulation of mucus, and, in rare instances, by the 
fact that the emphysema is greater on the right side. 



182 DISEASES OF THE RESPIRATORY ORGANS 

Occasionally there is almost suppression below, with pre- 
served respiration above, of the emphysematous type, 
and this so continuous as not to be explained by ob- 
struction of tubes. (2) Modifications in rhythm are 
not infrequent. These consist in a shortened (deferred) 
inspiratory, and a prolonged expiratory sound. In 
some instances an inspiratory sound is wanting, and 
an expiratory sound is alone heard. The prolonged 
expiratory sound in emphysema is always low in 
pitch and blowing or non-tubular in quality, in these 
respects differing from the prolonged expiration w^hich 
denotes solidification of lung, the latter being high 
in pitch and tubular in quality. These essential points 
of difference I claim to have been the first to have 
distinctly stated. 

The foregoing signs obtained by percussion and 
auscultation are those which are, in a positive sense, 
diagnostic of emphysema. Associated with these are 
certain important negative points, as follows: vocal 
resonance, vocal fremitus, and bronchial whisper are 
not notably altered. These negative points suffice to 
exclude other affections than emphysema. 

Signs obtained by inspection are quite distinctive 
of this affection. Emphysema, existing in a marked 
degree, causes a characteristic deformity of the chest; 
the anterior surface is bulging, giving to the chest 
an abnormally rounded, bow-windowed, or barrel- 
shaped appearance, the lower part appearing to be 
contracted. This deformity occurs when the emphy- 
sema has been developed in early life. The move- 
ments of the chest in inspiration are characteristic. 



PULMONARY OR VESICULAR EMPHYSEMA 183 

In tranquil breathing there is but little movement 
of the upper and anterior regions, but in forced breath- 
ing the sternum and ribs move together as if they 
were one solid piece. The lower portion of the chest 
and the epigastrium are retracted in inspiration, or 
the retraction may be only apparent; the costal angle 
is diminished, the ribs and cartilages connected with 
the sternum being sometimes on a line; the soft parts 
above the clavicle and sternum are often notably 
depressed with inspiration. Owing to depression of 
the heart downward and inward, the cardiac impulses 
are seen and felt in the epigastrium. Percussion and 
vocal resonance show the superficial cardiac region to 
be diminished or lost, the upper lobe of the left lung 
covering this space. There may be more or less ante- 
rior curvature of the spine, and the lower portions 
of the scapulae may project, so that sometimes the 
plane of these bones is almost horizontal. These 
striking appearances characterize cases in which emphy- 
sema exists in a marked degree, and especially w r hen the 
affection dates from early life. They are less marked 
or wanting if the emphysema be moderate in degree, 
and it have taken place in middle-aged persons or 
those advanced in years. 

In the variety of emphysema distinguished as 
senile, or senile atrophy of the lungs, in which there is 
coalescence of air-vesicles from destruction of the cell- 
walls without increased volume of the affected lobes, 
the diagnosis is to be based on the vesiculotympanitic 
resonance on percussion, weakened respiratory mur- 
mur, with, perhaps, the alterations in rhythm, sinking 



184 DISEASES OF THE RESPIRATORY ORGANS 

of the soft parts above the clavicles, and the negative 
points, exclusive of deformity of the chest, which have 
been described. 

Emphysema can hardly be confounded with any 
other affection than phthisis. The differentiation 
between these two affections is sufficiently easy if 
the diagnostic points, positive and negative, of the 
former, be appreciated. Phthisis occurring in a patient 
affected with emphysema makes a somewhat difficult 
problem in diagnosis; but, by strict attention to the 
associated history and symptoms, together with 
thorough examination of the sputum, errors will 
usually be avoided. Association of emphysema and 
pulmonary tuberculosis is not as uncommon as was 
formerly thought. 

Owing to the frequency with which an asthmatic 
element enters into the clinical history of emphysema, 
the dry bronchial (sibilant and sonorous) rales are 
often present, even when paroxysms of asthma do 
not occur. 



PLEURISY, ACUTE AND CHRONIC— EMPYEMA 
— HYDROTHORAX 

In the first stage of acute pleurisy — that is, prior 
to the effusion of liquid — the physical conditions 
are, the presence of more or less recently exuded, 
soft lymph upon the pleural surfaces, which are now 
in contact, and restrained movements of respiration 
on the affected side in consequence of the pain which 



PLEURISY, EMPYEMA, AND HYDROTHORAX 185 

they occasion. In the second stage, serous liquid 
accumulates within the pleural cavity, the quantity 
varying in different cases, sometimes, although rarely, 
filling the chest on the affected side. In proportion 
to the quantity of liquid, the space over which the 
pleural surfaces are in contact is restricted, the move- 
ments of these surfaces over each other are limited, 
and the lung is condensed. In the third stage the 
quantity of liquid decreases, the space over which 
the pleural surfaces are in contact increases, and the 
compressed lung is more or less expanded. The lymph 
upon the pleural surfaces becomes more dense and 
adherent. The surfaces may become agglutinated by 
the intervening lymph. Finally, in convalescence, 
permanent adhesions may result from the production 
or growth of areolar tissue. In subacute and chronic 
pleurisy there is the same series of physical conditions, 
the points of difference being, as a rule, a less amount 
of exudation, and a greater amount of effused liquid. 
The quantity of liquid in chronic pleurisy is often 
sufficient to compress the lung into a small solid mass 
situated at the upper and posterior part of the chest 
and to dilate the affected side. The heart is often 
removed from its normal situation. If the pleurisy 
be on the left side, the heart may be pushed laterally 
beyond the right margin of the sternum; if the pleurisy 
be on the right side, the heart is pushed laterally to the 
left of its normal situation. 

In empyema the accumulation of pus is apt to be 
still greater than that of serous effusion in simple 
chronic pleurisy, causing, of course, greater dilatation 
of the chest, and more displacement of the heart. 



186 DISEASES OF THE RESPIRATORY ORGANS 

In these varieties of pleurisy the affection, with 
rare exceptions, is unilateral. 

In hydrothorax the conditions differ, (1) as regards 
the absence of the exudation of lymph; (2) the 
affection is usually bilateral, the effusion of liquid taking 
place in both pleural cavities; and, (3) although 
the quantity of liquid may be considerably greater 
on one side, and this is almost invariably the right 
side, the accumulation very rarely, if ever, is sufficient 
to cause much dilatation of the chest on that side„ with 
complete condensation of the lung, and notable dis- 
placement of the heart. 

The signs in the first stage of acute pleurisy are 
relative feebleness of the respiratory murmur on the 
affected side, from the restrained respiratory move- 
ments on that side, and a rubbing friction-sound. 
The friction sound cannot be heard if only the dia- 
phragmatic or mediastinal pleura is inflamed. The 
former sign is not distinctive of pleurisy, being present 
when the respiratory movements on one side are re- 
strained by pain in intercostal neuralgia and pleuro- 
dynia. A friction-sound is not always obtained. In 
the absence of this sound the physical diagnosis can- 
not be made with positiveness prior to the effusion 
of liquid. 

When in doubt as to the site of origin of rales which 
may be friction-sounds or pulmonary crepitations, if 
the patient cough, the character of pulmonary rales is 
usually altered, and they may even disappear while 
pleuritic friction-sounds are unaffected. Also pressure 
of the stethoscope or hand may intensify the friction 



PLEURISY, EMPYEMA, AND HYDROTHORAX 187 

rub but does not alter the pulmonary crepitation. The 
friction sound is usually, but not invariably, heard 
only in inspiration. Assuming that the general and 
local symptoms point to an acute inflammatory affec- 
tion, the differential diagnosis relates to pleurisy 
and pneumonia. A pleural friction-sound may be 
present in the latter as well as the former of these 
two affections. The common sign of pneumonia, 
the crepitant rale, being wanting, the differentiation, 
in this stage, must rest on diagnostic points pertain- 
ing to the symptoms. The crepitant rale may occur 
at the inception of pleurisy, without coexisting pneu- 
monia, the mechanism of production being the same 
as in pneumonia. 

In the second stage of acute pleurisy the diag- 
nostic signs are those which denote the presence of 
liquid within the pleural cavity. These signs are 
simple and distinctive. There is either dulness or 
flatness on percussion at the base of the chest, extend- 
ing upward a distance proportionate to the quantity 
of liquid. If the trunk be in a vertical position — that 
is, the patient sitting or standing — the line of demar- 
cation between the dulness or flatness and pulmonary 
resonance on the anterior aspect of the chest is curved, 
following somewhat more than the downward curva- 
ture of the ribs in the axilla, and approaching the area 
of cardiac dulness in the left, or the liver or cardiac 
dulness on the right side, in a downward slanting 
direction. Posteriorly, the line of dulness or flatness 
is found to be a curve, starting about two inches from 
the posterior median line, and reaching its highest 
point in a line drawn vertically through the tip of 



188 DISEASES OF THE RESPIRATORY ORGANS 

the scapula, the curve then descending in the axilla, 
to reach the liver or cardiac dulness in front, according 
to the side and the amount of the effusion (Ellis', or 
Garland's line). 

Having ascertained the line forming the upper bound- 
ary of dulness or flatness on the anterior aspect of 
the chest, the patient sitting or standing, if the posi- 
tion be changed to recumbency on the back, and the 
pulmonary resonance be found then to extend more or 
less below this line, this fact is demonstrative proof 
of the presence of liquid. Where there is free pleuritic 
exudate on one side, there is found with considerable 
uniformity a triangular area of dulness on the opposite 
or unaffected side. The base of this area is made by 
the line of the base of the lung, and extends two to 
three inches from the posterior median line; the ver- 
tical side is somewhat longer usually and is as high 
in the mid-line as the upper level of the fluid on the 
affected side. This is known as the paravertebral 
triangle of dulness. Proof in this way is obtained in a 
large majority of cases, the exceptional cases being 
those in which the pleural surfaces are united, either 
by agglutination or permanent adhesions, above the 
level of the liquid. 1 The resonance on percussion 

1 An additional means of determining the level of the fluid 
especially at the right base posteriorly where the presence of 
the liver may cause confusion on percussion is by tapping one 
coin held firmly against the upper chest in front with another 
coin, when the ear below the level of the fluid behind will detect 
a much better transmission of the sound thus produced than 
when the ear is above the level of the fluid. Flatness oyer 
fluid is usually more intense and the sense of resistance to the 
pleximeter finger greater than over consolidated lung. 



PLEURISY, EMPYEMA, AND HYDROTHORAX 189 

over the lung above the level of the liquid is gener- 
ally vesiculotympanitic — the intensity increased, the 
pitch raised, the vesicular and the tympanitic quality 
combined. Sometimes there is so little vesicular 
quality in this vesiculo-tympanitic resonance that it 
may seem to be purely tympanitic, and is suggestive 
of pneumothorax. Associated signs will always pre- 
vent this error of observation. As a rule, vocal reso- 
nance and fremitus are either notably lessened, or 
suppressed over the portion of the chest situated below 
the level of the liquid. There are occasional excep- 
tions to this rule. The respiratory sound below the 
level of the liquid is suppressed. If any be heard, it 
is transmitted either from the lung above the liquid, 
or laterally, from the lung on the other side of the 
chest. Above the liquid the respiratory sound, as a 
rule, is weakened. If the amount of liquid be sufficient 
to produce much condensation of lung, the respiratory 
sound is broncho-vesicular. Sometimes, owing to the 
pleural surfaces above being adherent, a strip of lung at 
the level of the liquid is sufficiently condensed by 
compression to give a bronchial respiration. Under 
these circumstances, there will be either broncho- 
phony or the modification of that sign known as 
egophony. If the lung be not sufficiently compressed 
for the production of these signs of solidification, the 
vocal resonance is simply more or less increased. 
The fremitus is usually increased above the liquid. 
Over the unaffected side the respiratory murmur is 
increased in intensity. 

The foregoing signs are present when the pleural 



190 DISEASES OF THE RESPIRATORY ORGANS 

cavity is partially filled ; a quarter, a half, or two- 
thirds of the thoracic space being occupied by liquid. 
The signs present when the cavity is completely filled 
will be presently stated in connection with chronic 
pleurisy. 

The signs which have been stated show not only 
the presence of liquid but its quantity. By means 
of these signs are readily ascertained the progressive 
increase or decrease in the quantity of liquid, and 
its disappearance. After the liquid has disappeared, 
often notable dulness on percussion remains for some 
time, showing the presence of lymph not yet absorbed. 
During the decrease of the liquid, and after its dis- 
appearance, a friction-murmur is often perceived. 
This murmur is now apt to be rough — a rasping, 
grating, or creaking sound. It may be loud enough to 
be heard by the patient, and by others at a distance 
from the chest. It continues sometimes for a con- 
siderable period. 

The physical diagnosis in cases of chronic pleurisy, 
when the liquid occupies a portion only of the 
thoracic space, rests, of course, on precisely the same 
signs as in cases of acute pleurisy. If, however, the 
chest on the affected side be filled and dilated, certain 
of the signs which have been stated are wanting, and 
others are added. The affected side is everywhere 
flat on percussion. Flatness on percussion over the 
whole of one side, the affection being chronic, denotes, 
as a rule, with rare exceptions, either chronic simple 
pleurisy or empyema. Respiratory sound is wanting 
except at the summit over or near the compressed 



PLEURISY, EMPYEMA, AND HYDROTHORAX 191 

lung, where it is bronchial. Some cases offer an impor- 
tant exception to this rule, namely, the bronchial 
respiration is diffused over the greater part, or even 
the whole, of the affected side. The student should 
bear in mind this fact, otherwise the diffusion of the 
bronchial respiration may lead to the suspicion that 
the flatness on percussion denotes solidification of 
lung and not the presence of liquid. Other signs, 
however, should always correct this error. Vocal 
resonance and fremitus are, with some exceptions, 
either suppressed or notably diminished over the whole 
of the affected side. Generally, even when the chest is 
not dilated, the intercostal depressions are lessened or 
abolished. If the walls of the chest be thinly covered 
with integument, the tw T o sides present a marked 
contrast in this respect. This is seen especially at 
the middle and lower regions of the chest anteriorly 
and laterally. It is especially marked at the end of 
the inspiratory act. If the affected side be dilated, 
this is apparent on inspection, and may be deter- 
mined accurately by semicircular or diametric men- 
suration, calipers being required for the latter. The 
respiratory movements on the affected side are dim- 
inished or annulled, and they are increased on the 
healthy side, the two sides affording a marked contrast 
in this regard. If the pleurisy be on the left side, the 
impulses of the heart are not infrequently felt on 
the right of the sternum. If the impulses cannot 
be felt, auscultation shows the maximum of the inten- 
sity of the heart sounds to be more or less removed 
to the right. If the pleurisy be on the right side 



192 DISEASES OF THE RESPIRATORY ORGANS 

the impulses or sounds of the heart denote more or 
less displacement laterally to the left, and this altered 
position may be still further determined by percussion 
of the cardiac border adjacent to healthy lung. The 
intensity of the respiratory murmur on the unaffected 
side is notably increased. 

In cases of empyema the same signs are present 
as in chronic pleurisy. The character of the liquid 
does not alter appreciably any of the signs which 
have been stated. Dilatation of the affected side of 
the chest is more apt to occur, and to be more marked 
than in simple pleurisy. The differential diagnosis 
between these two varieties of pleurisy is to be made 
with positiveness by the introduction of the needle 
of a hypodermic syringe having good suction force, 
previously cleaned and carbolized, and obtaining 
enough of the liquid to ascertain its character. 

When the left pleural cavity is filled with pus, the 
movements of the heart sometimes give to the affected 
side of the chest an impulse perceived by the eye 
and touch; hence the term, pulsating empyema. This 
condition has been observed even when the empyema 
has been confined to the right pleural cavity. After 
a spontaneous perforation of the chest, followed by a 
circumscribed purulent collection beneath the integu- 
ment, communicating with the pus within the pleural 
cavity, the tumor thus formed sometimes has a strong 
pulsation which is synchronous with the ventricular 
systole, and may give rise to the suspicion of aneurism. 

In cases of hydrothorax, the signs denote partial 
filling of the chest on both sides. The affection is 



PLEURISY, EMPYEMA, AND HYDROTHORAX 193 

bilateral. Generally the quantity of liquid in the 
two sides is not equal, and there is often a notable 
disparity in this respect. Friction-sounds are never 
present. Variation of the level of the liquid with 
change of the position of the patient from the ver- 
tical to the horizontal is nearly always determinable. 
Hydrothorax, meaning by this term a purely dropsical 
affection, is to be differentiated from double pleurisy 
with effusion. The history and symptoms, taken in 
connection with the signs, suffice for this discrimination. 

Exceptional Physical Signs in Pleurisy. 1 — "The vocal 
fremitus may not be lost below the level of the fluid. 

"Above the level of the fluid, over the compressed 
lung, there may be cavernous breathing and gurgling 
rales. 

"A sub-crepitant rale may be heard below the level 
of the fluid, the level being demonstrated by the 
aspirator. 

"Sacculated effusions give irregular physical signs 
which vary with the position of the fluid. The effu- 
sions are most easily made out if they are in contact 
with the wall of the chest. 

"Most of the sacculated pleurisies I have seen have 
been situated about the root of the lung, gave the 
maximum flatness at some point between the scapula 
and the vertebral column, and were best aspirated at 
the point of maximum flatness. In some of these 
cases there was flatness and absence of breathing 
over the fluid; in some, flatness and bronchial voice 

1 Delafield: Lectures on the Practice of Medicine, 1903. 
13 



194 DISEASES OF THE RESPIRATORY ORGANS 

and breathing; in some there was pulmonary resonance 
with bronchial voice and breathing over the lower part 
of the chest where there was no fluid. " 



PNEUMOTHORAX— PNEUMO-HYDROTHORAX 
— PNEUMO-PYOTHORAX 

In the extremely rare cases of pneumothorax, that 
is, as distinguished from pneumo-hydrothorax and 
pneumo-pyothorax, the physical conditions are: the 
presence of air partially or completely occupying the 
thoracic space, and condensation of lung in propor- 
tion to the space occupied by air. 

The diagnostic signs are, a purely tympanitic 
resonance over a portion or the whole of the affected 
side of the chest: suppression of the vesicular mur- 
mur over a space corresponding to that in which 
tympanitic resonance is obtained, with notable dimi- 
nution or suppression of vocal resonance and fre- 
mitus. Over the compressed lung, if the condensation 
amount to complete or considerable solidification, 
there will be bronchial respiration and bronchophony; 
if the solidification be neither complete nor consider- 
able, there will be broncho-vesicular respiration with 
increased vocal resonance and fremitus. The accu- 
mulation of air may be sufficient to dilate the affected 
side, and to restrain or annul the respiratory move- 
ments on this side. The appearances on inspection 
are then precisely the same as in the cases of chronic 
pleurisy and empyema, in which the affected side i§ 



PNEUMOTHORAX— PNEUMO-PYOTHORAX 195 

dilated from the presence of liquid. Pneumothorax 
is, however, at once differentiated by the tympanitic 
resonance on percussion. If one side of the chest be 
more or less dilated, and the resonance over the side 
be purely tympanitic, the thoracic space must be 
filled, not with liquid but with air. The intensity 
of the respiratory murmur on the healthy side is 
increased. The heart is displaced toward the un- 
affected side of the chest. 

In the great majority of cases in which the pleural 
cavity contains air, there is also present more or less 
liquid, which may be serous or purulent. The affec- 
tion is then known as pneumo-hydrothorax if the 
liquid be serous, and pneumo-pyothorax if it be pur- 
ulent. The physical conditions are the same as in 
pneumothorax, with the addition of the presence 
of liquid. The relative proportions of liquid and air 
in different cases are variable, and, also, in the same 
case at different periods. 

The physical diagnosis of pneumo-hydrothorax 
and of pneumo-pyothorax, as distinguished from 
pneumothorax, embraces the signs of liquid, in addi- 
tion to those of air, within the pleural cavity. If 
the quantity of liquid be large or considerable, per- 
cussion at the base of the chest gives flatness, extend- 
ing upward more or less, and tympanitic resonance 
above, the patient either sitting or standing. A 
change from the vertical to the horizontal position 
invariably causes variation of the upper limit of the 
flatness, inasmuch as the liquid and air change their 
relative situations without an exception. The quan- 



19G DISEASES OF THE RESPIRATORY ORGANS 

titv of liquid is determined approximatively, by ascer- 
taining the space over which the flatness on percus- 
sion extends. The line which divides the flatness 
and the tympanitic resonance does not accurately 
denote the level of the liquid, because tympanitic 
resonance is transmitted a certain distance below 
this level, hence it is always to be assumed that the 
level of the liquid is somewhat higher than the upper 
boundary of the flatness. 

In either pneumothorax, pneumo-hydrothorax, or 
pneumo-pyothorax a group of auscultatory signs is 
often found which are highly diagnostic, indeed almost 
pathognomonic. These signs are amphoric respiration, 
amphoric voice or echo, and metallic tinkling. The 
amphoric and the tinkling sounds may be present, 
either without the other, but they are not infrequently 
associated. Both signs are absent in some cases and 
they are not present in the same case at all times; 
their absence, therefore, by no means excludes the 
affections, and they are not essential to the diagnosis. 
When present they denote either air, or air and liquid, 
in the pleural cavity with perforation of lung, or a large 
phthisical cavity. Their occurrence in the latter is 
comparatively rare, and whenever they are associated 
with other signs already stated, their diagnostic 
import is demonstrative. 

Pneumo-hydrothorax or pneumo-pyothorax may 
almost invariably be diagnosticated instantly by the 
presence of a succussion sound. Whenever distinct 
splashing is produced by succussion and referable to 
the chest, that is, not produced within the stomach, 



ACUTE LOBAR PNEUMONIA 197 

it is demonstrative of the presence of air and liquid 
within the pleural cavity. 

Whenever there is a large free air space within the 
thorax, such as occurs in the conditions described above, 
a distinctive quality is given to the sound heard through 
the affected side, when a coin is tapped sharply against 
another held firmly in contact with the chest-wall. 
The sound produced, instead of being distant and 
mufHed as through a normal lung, is clear, intense, 
ringing, and can be likened to the sound a small pebble 
makes when dropped into a deep w r ell. 



ACUTE LOBAR PNEUMONIA 

In the first stage of this disease there is an abnor- 
mal accumulation of blood within the vessels of the 
affected lobe (active congestion or hyperemia), w T ith 
some exudation within the air-vesicles and bronchi- 
oles. Generally there is some exuded lymph upon 
the pleural surface, this being due to circumscribed 
dry pleurisy. In most cases there is also circum- 
scribed bronchitis, which is limited to the tubes within 
the affected lobe. In the second stage there is solidi- 
fication due to the increase of exudation within the 
air-vesicles. The solidification, at first limited, extends 
either rapidly or slowly, as a rule, over the whole 
lobe. Exceptionally more or less liquid effusion into 
the pleural cavity takes place (pleuro-pneumonia), 
the pleurisy then extending beyond the limits of the 
affected lobe. In this stage the pneumonia may involve 



198 DISEASES OF THE RESPIRATORY ORGANS 

either another lobe of the lung primarily affected, 
or a lobe of the opposite lung, and sometimes the 
disease, by successive invasions, extends over the whole 
of one lung, together with a lobe of the opposite lung. 
The pneumonia, in these secondary invasions, is 
usually accompanied by pleurisy and bronchitis. 
In the stage of resolution the solidification of the 
affected lobe or lobes decreases, sometimes rapidly 
and sometimes slowly, until the normal condition is 
restored. If resolution does not take place, and the 
disease pass into the stage of purulent infiltration, 
the air-vesicles and bronchial tubes contain a puruloid 
liquid in greater or less quantity. Exceptionally pus 
is collected in a cavity, or in cavities, constituting 
pulmonary abscess. 

The physical diagnosis of acute lobar pneumonia 
in the first stage must be based on the presence of 
the crepitant rale, with moderate or slight dulness 
on percussion, and diminished vesicular respiratory 
murmur over the affected lobe. There is some- 
times in this stage a pleuritic rubbing sound over 
the affected lobe. The crepitant rale is not always 
present, and hence the affection cannot be excluded 
by the absence of this sign. When present, taken 
in connection with the symptoms, this sign is of great 
diagnostic value. It is important not to mistake for 
this sign fine bubbling, or the subcrepitant rale. When 
the crepitant rale is wanting, a positive physical diag- 
nosis must be deferred until more or less of the affected 
lobe becomes solidified, that is, when the disease 
passes into the second stage. 



ACUTE LOBAR PNEUMONIA 199 

The diagnosis in the second stage is to be based 
on the signs of solidification furnished by ausculta- 
tion and percussion. The auscultatory signs are the 
broncho-vesicular, followed by the bronchial respi- 
ration; increased vocal resonance, followed by bron- 
chophony, and increased bronchial whisper, followed 
by whispering bronchophony. The signs of solidi- 
fication are manifested at first within a circumscribed 
space, situated over either the upper, the lower, or 
the middle portion of the affected lobe, and either 
rapidly or slowly the signs extend, in most cases over 
the entire lobe. The crepitant rale, if it have been 
present in the first, generally disappears in the second 
stage. Sometimes, however, it is not entirely lost 
in this stage. The broncho-vesicular respiration, 
increased vocal resonance, and increased bronchial 
whisper are present when the solidification is slight 
or moderate; the bronchial respiration, bronchophony, 
and bronchophonic whisper take their place when the 
solidification becomes considerable or complete. The 
latter signs, as a rule, speedily follow, inasmuch as 
the solidification in most cases quickly becomes com- 
plete or considerable. The foregoing three signs, 
denoting considerable or complete solidification, are 
usually present. Bronchial respiration, however, is 
sometimes present without bronchophony, and vice 
versa. Either, present alone, suffices to show the 
existence and the extent of the solidification. Moist 
bronchial or bubbling rales are sometimes, but rarely, 
heard over the affected lobe. 

There is notable dulness on percussion in the second 



200 DISEASES OF THE RESPIRATORY ORGANS 

stage. The dulness may approximate and even amount 
to flatness. If a single lobe be affected, the dulness 
or flatness extends over a space corresponding to that 
occupied by the lobe or the portion of it which is 
solidified. In the anterolateral aspects of the chest, 
the dividing line between the solidified and the healthy 
lobe is readily ascertained by percussion, and this line 
is coincident with the interlobar fissure. 1 It some- 
times happens that the upper and the lower lobe of the 
right lung are affected, the middle lobe not becoming 
involved. The space corresponding to the middle 
lobe may then form an island of resonance surrounded 
by notable dulness on percussion. 

Whenever one lobe of a lung is affected, the reso- 
nance over the unaffected part of the same lung is 
abnormally increased, the pitch is raised, and the 
quality is vesiculotympanitic ; vesiculotympanitic 
resonance, in other words, is produced. This renders 
more marked the contrast between dulness over the 
solidified, and resonance over the healthy, lobe. 

Over a portion of an upper lobe in the second stage, 
instead of notable dulness or flatness, there may be 
marked tympanitic resonance. This resonance pro- 
ceeds from air within the trachea and the bronchi 
exterior to the lungs, the lung substance being com- 
pletely solidified; it is chiefly or especially marked 
over the site of these air-tubes. In some cases the 

1 With reference to the localization of pneumonia in the 
upper or lower lobes the situations of the interlobar fissures on 
the anterior, posterior, and lateral aspects of the chest are to be 
kept in mind (vide Figs. 1, 2, 3, 4, pages 42 to 45). 



ACUTE LOBAR PNEUMONIA 201 

tympanitic resonance has either the cracked-metal 
or the amphoric intonation. These signs, per se, 
might suggest either pneumothorax or phthisical 
cavities; the associated respiratory and vocal signs, 
however, show only solidification of lung. In cases of 
pneumonia affecting the left lung, a tympanitic reson- 
nance is not infrequently propagated from the stomach 
more or less upward over the affected side of the 
chest. This may be readily traced to the stomach. On 
the right side, a tympanitic resonance is sometimes 
propagated a certain distance upward from the 
transverse colon. 

The commencement of the stage of resolution is 
denoted by a broncho-vesicular respiration. The 
first change observed is the presence of a little vesi- 
cular quality in the inspiratory sound. When this is 
observed, the respiration is no longer bronchial, but 
has become broncho-vesicular, although the pitch 
is still high, and the expiration is prolonged, high, 
tubular. This slight change shows that air begins 
to enter the pulmonary vesicles. As resolution goes 
on, more and more of the vesicular takes the place 
of the tubular quality in the inspiratory sound, and 
the pitch is lowered in proportion; the expiratory sound 
becomes proportionately less and less prolonged, its 
pitch lowered, its quality less tubular, until, at length, 
the normal characters of the respiratory murmur are 
regained. Resolution is then complete. 

While the broncho-vesicular respiration is under- 
going the modifications just stated, the vocal sounds 
have corresponding changes. Bronchophony per- 



202 DISEASES OF THE RESPIRATORY ORGANS 

sists for some time after the respiration has become 
broncho- vesicular, and then disappears, increased vocal 
resonance generally taking its place and persisting 
until resolution is completed. The bronchial whisper 
loses its bronchophonic characters, and is simply 
increased until its normal characters are regained. 
While the solidification is complete, the vocal fremitus 
may, or may not, be increased. It is sometimes dim- 
inished. When, however, resolution has so far pro- 
gressed that bronchophony is lost, the fremitus is 
usually greater than in health, and so continues, but 
progressively lessening until the solidification entirely 
disappears. 

During the progress of resolution, the dulness on 
percussion diminishes in proportion as air enters 
the air-vesicles. If tympanitic resonance have been 
present over the upper lobe, this gives place to a 
vesicular resonance. Some dulness, however, remains 
after the completion of resolution, and persists until 
the exuded lymph on the pleural surface is absorbed. 
The amount of dulness remaining when the respi- 
ratory and vocal signs denote resolution, is propor- 
tionate to the quantity of exudation incident to the 
associated pleurisy. 

In this stage the crepitant rale not infrequently 
returns, if it have entirely disappeared during the 
second stage, and if it have persisted, it is more marked 
and diffused. It is now known as the returning crepi- 
tant rale. More frequently the rale in this stage is 
a fine bubbling or the so-called sub-crepitant. Both 
rales are not infrequently associated, and, from the 



CIRCUMSCRIBED PNEUMONIA 203 

distinctive characters of each, they are readily dis- 
tinguished. Moist rales, more or less fine or coarse, 
are not infrequent. The pitch of these rales remains 
more or less high until the solidifying exudation is 
completely absorbed. 

If the affection pass into the stage of purulent infil- 
tration, the respiratory sounds are feeble or suppressed, 
having, if present, more or less of the bronchial char- 
acters. Bubbling bronchial rales, coarse and fine, 
are abundant. Weak bronchophony may persist, or 
the vocal resonance may be diminished. Fremitus 
may, or may not, be increased. Notable dulness or 
flatness on percussion remains. 

If the pneumonia result in pulmonic abscess, there 
will be notable dulness or flatness on percussion within 
a circumscribed space, together with absence of respi- 
ratory murmur, and diminished or suppressed vocal 
resonance. These signs warrant a probable diagnosis 
which is corroborated by the sudden expectoration 
of pus in a considerable quantity. The signs just 
stated may then be followed by those denoting a 
cavity — namely, cavernous respiration and whisper, 
with intense vocal resonance. 



CIRCUMSCRIBED PNEUMONIA— EMBOLIC PNEU- 
MONIA— HEMORRHAGIC INFARCTUS OR 
PULMONARY APOPLEXY 

The form of pneumonia known as lobular pneu- 
monia, occurring in children, has been considered 



204 DISEASES OF THE RESPIRATORY ORGANS 

(vide Bronchitis seated in small-sized tubes). When- 
ever circumscribed, as a rule, pneumonia is secondary 
to some other pulmonary affection. Circumscribed 
pneumonia, giving rise to an intra-vesicular exudation, 
which may disappear readily by resolution or absorp- 
tion, is not very infrequent in cases of phthisis. The 
signs are those which represent solidification of lung 
within an area more or less circumscribed; but the 
differentiation, from the solidification proper to phthisis, 
can only be made with positiveness, after the signs 
have shown that the solidification has notably dim- 
inished, or disappeared. 

In embolic pneumonia there may be dulness on 
percussion, with feeble bronchial or broncho-vesicular 
respiration, or suppression of respiratory sound, w r eak 
bronchophony or increase of vocal resonance, within 
a circumscribed space, or within spaces, generally 
on the posterior aspect of the chest, and oftenest 
on the right side. These signs, taken in connection 
with the symptoms and pathological conditions which 
are consistent with the supposition of emboli received 
into the right side of the heart, namely, when the 
pulmonary symptoms follow puerperal disease, ulcers, 
wounds, injuries, or venous thrombosis, render the 
diagnosis quite positive. If, however, the pulmonary 
affection consist of small disseminated nodules, the 
foregoing signs will not be present. The diagnosis 
then must be based on the history and symptoms, 
taken in connection with the exclusion of other pul- 
monary affections by the absence of signs, which should 
be present if they existed. Bubbling rales, the pitch 



PULMONARY GANGRENE 205 

more or less raised, at different situations may indicate 
the probable sites of the nodules. There may be 
pleuritic friction-sounds. The signs may show, as 
a complication, pleurisy with effusion. 

Extravasation of blood (pneumorrhagia), if it be in 
small spaces, gives rise to no definite physical signs. 
If, however, extravasation extend over a considerable 
space, there will be dulness on percussion, with feeble 
or suppressed respiratory sound within an area corre- 
sponding to the extent of the extravasation. Within, 
and near this area, there will be likely to be moist 
bronchial rales more or less fine or coarse. 



PULMONARY GANGRENE 

In diffused pulmonary gangrene the physical signs 
are those of solidification extending over the greater 
part or the whole of a lobe. The diagnosis, how- 
ever, can only be made when, in connection with 
these signs, there are present the characteristic fetor 
of the breath and expectoration. 

In circumscribed gangrene there is dulness or flat- 
ness on percussion within an area corresponding to 
the extent of the affection, with either suppression 
of respiratory sound or bronchial respiration, and 
the vocal signs of solidification. Within and near 
this space moist bronchial rales, more or less raised 
in pitch, are likely to be heard. The situation is 
usually on the posterior aspect of the chest. These 
signs do not suffice for a positive diagnosis without 



206 DISEASES OF THE RESPIRATORY ORGANS 

the characteristic breath and expectoration. Cavern- 
ous signs may appear after the gangrenous portion 
of lung has sloughed away and been expectorated. 

PULMONARY EDEMA 

The physical condition expressed by the term pul- 
monary edema is the presence of effused serum within 
the air-vesicles. With this condition is associated 
more or less pulmonary congestion. 

In cases of pulmonary edema developed rapidly 
and largely in connection with renal disease, with 
obstruction at the mitral orifice of the heart, or with 
both these affections combined, giving rise to great 
dyspnea, and liable to end speedily in death, the 
following are the diagnostic signs: Dulness on per- 
cussion on both sides of the chest, especially over the 
lower lobes, fine bubbling or so-called subcrepitant 
rales diffused over the chest on both sides, together 
with coarser bubbling sounds, and the murmur of 
respiration notably weak or suppressed over the 
lower lobes. Inasmuch as the lungs are not solidi- 
fied the rales are low in pitch. The vocal signs of 
solidification are, of course, wanting. Occasionally 
the crepitant rale is mingled with the fine bubbling 
sounds. 

This form of the affection is to be differentiated 
from hydrothorax with large effusion, and from so- 
called capillary bronchitis. Hydrothorax is always 
associated with more or less anasarca, or general 
dropsy, whereas, pulmonary edema, even when depen- 



PULMONARY EDEMA 207 

dent on renal disease, may occur without dropsical 
effusion elsewhere. Moreover, the presence of liquid 
within the pleural cavities, and its amount, may 
always be determined demonstratively in cases of 
hydrothorax (vide Pleurisy with effusion and Hydro- 
thorax) . Capillary bronchitis occurs chiefly in children. 
The so-called subcrepitant rale on both sides of the 
chest is the diagnostic sign of this affection, but it 
is not accompanied by dulness on percussion, except 
in so far as the bronchitis may be associated with 
lobular pneumonia or collapse of pulmonary lobules. 
The rapid development of the edema and its patho- 
logical connections are diagnostic points to be taken 
into account. 

Pneumonia is excluded by the fact that the affec- 
tion is at the beginning bilateral, and by the absence 
of the signs of solidification of lung. 

Pulmonary edema less in degree and diffusion, 
has, of course, the same signs, not as marked and 
not as extensive — namely, dulness on percussion and 
fine bubbling sounds or the so-called subcrepitant 
rales. In this form the affection is bilateral, and 
seated especially in the posterior and inferior por- 
tions of the lungs. Moreover, this form has the 
same pathological connections, namely, with disease 
of the kidneys, and mitral lesions of the heart. The 
low pitch of the bronchial rales, and the absence of 
the respiratory and vocal signs of solidification, to- 
gether with the fact of the affection being bilateral, 
and the coexistence of disease of the heart or kidneys, 
constitute the basis of a positive diagnosis, 



208 DISEASES OF THE RESPIRATORY ORGANS 

Hypostatic congestion of the lungs may occasion 
a certain amount of pulmonary edema. The physi- 
cal diagnosis is to be based on bilateral dulness on 
the posterior aspect of the chest, with low-pitched, 
fine bubbling sounds, or the so-called subcrepitant 
rales on both sides, these signs occurring under cir- 
cumstances which lead to the supposition of this 
form of congestion. 

NEOPLASMS OF LUNG— TUMORS WITHIN THE 
CHEST 

Neoplastic growths in the lungs are usually in 
the form of nodules varying in size from that of a 
pea to a hen's egg, disseminated throughout one 
lung or both lungs, in greater or less numbers. These 
disseminated nodules, if of small size, have no well- 
marked, definite diagnostic signs. If limited to a lung, 
or if greater in number in one lung, they may occasion 
an appreciable dulness on percussion. They may also 
occasion feebleness of the respiratory murmur, and, 
owing to coexisting circumscribed bronchitis, moist 
bronchial rales may be heard at different points. 
These signs warrant a diagnosis when, as is usually 
the case, cancer is known to have existed elsewhere. 
With reference to diagnosis, it is to be borne in 
mind that, when cancer of the lung is secondary, 
both lungs are affected, and, when it is primary, the f 
affection is generally unilateral. 

If there be nodules of considerable size, there will 
be well-marked dulness on percussion in different 



NEOPLASMS OF LUNG 209 

situations, and the signs of solidification may be 
present, namely, either bronchial or broncho-vesicular 
respiration, either increased vocal resonance or 
bronchophony, and increased vocal fremitus. 

In some cases of unilateral carcinoma, the greater 
part, or the whole, of a lung may be infiltrated with 
the morbid growth, increasing its volume and giving 
rise to enlargement of the affected side, diminished 
respiratory movements or immobility, flatness on 
percussion, with diminished or suppressed respira- 
tory murmur, vocal resonance, and fremitus. If, as 
is usual, there be also more or less pleuritic effusion, 
the intercostal spaces may be pushed out to a level 
with the ribs. Here are the signs which denote chronic 
pleurisy with large effusion, and the differential diag- 
nosis cannot be made with positiveness until the 
fluid within the chest be withdrawn, and it be found 
that, irrespective of the bulging of the intercostal 
spaces, the physical signs remain. Exploration with 
a small trocar, or hollow needle, will settle the diag- 
nosis when there is no pleuritic effusion, and this 
procedure is unobjectionable. 

In other cases the neoplastic growth induces atrophy 
of the lung, diminishing its volume, and causing 
notable contraction of the affected side. The appear- 
ances on inspection are those which denote con- 
traction after chronic pleurisy, and they may be 
present also in cases of fibroid phthisis or cirrhosis 
of lung. The differential diagnosis must be based 
chiefly on diagnostic points relating to the history 

and symptoms. 
14 



210 DISEASES OF THE RESPIRATORY ORGANS 

Tumors within the chest, generally having their 
points of departure in the mediastinum, displace the 
lung in proportion to their size. They may cause 
considerable displacement of the heart, and produce 
more or less enlargement of the chest with dimin- 
ished respiratory movements. Enlargement of the 
subcutaneous veins, indicative of venous obstruction, 
is often to be observed. Over the site of the tumor, 
there will be either dulness or flatness on percussion. 
Generally respiratory sound is wanting, vocal reso- 
nance and fremitus being either diminished or sup- 
pressed. In the neighborhood of the primary bronchi 
and over lung compressed by the tumor, there may 
be bronchial respiration, with bronchophony and in- 
creased fremitus. If the chest be enlarged, its enlarge- 
ment is not likely to be as uniform as when it is dilated 
with liquid; this is a diagnostic point. The tumor, 
or the tumors, may not be confined to one side of the 
chest. It is to be borne in mind that pleurisy with 
effusion may exist as a complication, and this may 
serve to obscure the diagnosis. 

The physical diagnosis involves differentiation from 
pericarditis with effusion and aneurisms. These 
affections are to be excluded by the absence of their 
diagnostic signs. 

ACUTE MILIARY TUBERCULOSIS 

The physical condition in this affection is the pres- 
ence of a large number of the small bodies known 
as tubercles or miliary granulations, disseminated 



PHTHISIS 211 

throughout both lungs. Bronchitis is an associated 
affection. 

If the tubercles be about equally distributed in 
the two lungs, there is no abnormal disparity of the 
resonance on percussion between the two sides of 
the chest. A comparison, also, of the two sides 
may afford no disparity as regards the respiratory 
murmur, vocal resonance, and fremitus. Moist rales, 
due to the associated bronchitis, may be present in 
different situations. A physical diagnosis, under 
these circumstances, cannot be made with positive- 
ness. Physical exploration, however, is important 
in order to exclude other affections; and the negative 
result, taken in connection with the symptoms — 
hyperpyrexia, rapid pulse, accelerated breathing, etc. 
— renders the diagnosis extremely probable. The 
differential diagnosis involves discrimination from 
capillary bronchitis, and an essential fever w r ith a 
bronchial complication. The affection has been 
repeatedly mistaken for typhoid fever. 

The tubercles may be more abundantly distributed 
in one lung. A disparity in the resonance on per- 
cussion may then be apparent, and, perhaps, an 
abnormal increase of vocal resonance and fremitus. 
These signs, taken in connection with the symptoms, 
establish the physical diagnosis. 

PHTHISIS 

With reference to physical diagnosis, cases of phthisis 
may be conveniently distributed into three groups, as 



212 DISEASES OF THE RESPIRATORY ORGANS 

follows: (1) Cases in which the pulmonary affection 
is small, or cases of incipient phthisis; (2) cases in 
which the affection is moderate or considerable; and 
(3) cases in w T hich the affection has progressed to the 
formation of cavities, or cases of advanced phthisis. 1 

In cases of incipient phthisis the essential physical 
condition is the presence of small solidified masses, 
or nodules, the intervening vesicular structure not 
being affected. These nodules vary from the size 
of a pea to a filbert. In the vast majority of cases 
they are situated at or near the apex of either the 
right or the left lung. Generally, circumscribed capil- 
lary bronchitis coexists in proximity to the nodules. 
An intercurrent circumscribed pneumonia sometimes 
occurs, giving rise to transient solidification within 
a limited area. Dry circumscribed pleurisy situated 
over the affected portion of lung, generally occurs 
from time to time. 

In the cases of a moderate or a considerable pul- 
monary affection, the difference, as compared with 
the preceding group of cases, consists in the presence 
of nodules of large size, or solidification from the 
phthisical deposit extending over a space, or spaces, 
sufficient in size to give rise to well-marked physical 
signs. The solidification in these cases may be extended 

1 At present the so-called Turban, and National Association, 
classifications for clinical stages or groups of pulmonary tuber- 
culosis are so superior to any previously used, and are so 
universally followed at the present time, that the reader is 
urged to make use of them to the exclusion of less exact defi- 
nitions (see p. 350). — Ed. 



PHTHISIS 213 

by the development of circumscribed interstitial pneu- 
monia. The circumscribed bronchitis is greater, as 
a rule, in degree and extent; attacks of dry pleurisy 
may continue to occur, and the pleural surface becomes 
adherent. In these cases, generally, the affection, 
existing primarily in one lung, now exists in both 
lungs. The volume of the lung first affected, at the 
summit, is more or less diminished. Enlargement 
of the bronchial glands is usual, and these may be so 
situated as to press upon and diminish the calibre of 
one of the primary bronchi. In some cases, portions 
of lung in the neighborhood of solidified masses or 
nodules are emphysematous (vicarious emphysema). 

Cases of advanced phthisis are characterized by 
the presence of a cavity, or, commonly, of cavities, 
varying in number, size, rigidity or flaccidity of the 
walls, freedom of communication with bronchial 
tubes, and the nearness of their situation to the super- 
ficies of the lung. In cases of progressive phthisis, in 
addition to cavities, there is more or less solidifica- 
tion from phthisical exudation and interstitial pneu- 
monia. The volume of the lung at the summit is often 
notably diminished. The pleural surfaces are firmly 
adherent. If, however, the disease have been retro- 
gressive or non-progressive, there may be little or no 
solidification of lung, the cavity or cavities forming 
the only lesion. In cases of advanced phthisis, with 
very rare exceptions, both lungs are affected, and 
cavities often exist on both sides. 

The physical diagnosis in cases of incipient phthisis 
embraces what may be called direct and accessory 



214 DISEASES OF THE RESPIRATORY ORGANS 

signs. The accessory signs are those which repre- 
sent incidental affections — namely, circumscribed 
bronchitis, pleurisy, and pneumonia. The direct 
signs are those representing the essential condition, 
namely, the solidified masses or nodules. 

An important direct sign is dulness on percussion. 
Slight dulness on percussion at the summit of the 
chest, in front or behind, is a highly important sign, 
taken in connection with symptoms, of incipient 
phthisis. In determining that a relative dulness is 
abnormal, the student must bear in mind, in the first 
place, the normal disparity between the two sides. 
The right side at the summit is relatively somewhat 
dull on percussion in healthy persons. Due allowance 
is to be made for this normal disparity. In the second 
place, it is to be borne in mind that any deformity 
affecting the symmetry of the chest will affect the 
relative resonance on the two sides; and that a devia- 
tion from symmetry attributable to the position of 
the patient will occasion a disparity on percussion. 
In the third place, the rules for the practice of per- 
cussion must be kept in mind, in order to avoid 
producing apparently an abnormal disparity by the 
non-observance of these rules (vide p. 69 et seq.) . Normal 
resonance on percussion on the two sides is a strong 
point for the exclusion of incipient phthisis. 

The direct respiratory signs in incipient phthisis 
are the broncho-vesicular respiration and weakened 
vesicular murmur. To these is to be added a local- 
ized interrupted or wavy inspiratory murmur, as an 
occasional sign. Of course, familiarity with the 



PHTHISIS 215 

characters of the broncho-vesicular respiration is 
indispensable — the combination of the vesicular and 
the tubular quality in the inspiratory sound, with 
the pitch raised in proportion to the amount of tubu- 
larity, and the expiratory sound more or less pro- 
longed, high, and tubular. Not infrequently the 
only appreciable morbid modification is diminished 
intensity of the murmur. When this sign is present, 
it is probable that the lack of intensity is the reason 
for the absence of the characters of the broncho- 
vesicular modifications, that is, the latter sign would 
have been present were the respiratory sounds more 
intense. 

The direct vocal signs in incipient phthisis are in- 
creased vocal resonance, increased bronchial whisper, 
and increased fremitus. The other direct signs may 
be present without an appreciable morbid increase 
of the vocal resonance or fremitus. The increased 
whisper may also be wanting, but more rarely than 
the two other vocal signs. 

In deciding on the presence or absence of each 
and all of these direct signs, it is essential to know 
and to judge correctly of the disparity between the 
two sides of the chest at the summit in health. Nor- 
mally the resonance or percussion at the summit 
on the right side is slightly dull as compared with 
the left side; the inspiratory sound on this side has 
some tubularity in quality, and is somewhat raised 
in pitch; the expiratory sound ma}' be more or less 
prolonged, high, and tubular; the vocal resonance 
on the right side is always greater, the same being 



216 DISEASES OF THE RESPIRATORY ORGANS 

true of fremitus; the bronchial whisper is louder on 
the right side, and the intensity of the respiratory 
murmur is a little less on this side. Whenever it is 
a question as to a small phthisical affection at or near 
the apex of the right lung, it is a matter of experience 
and judgment to decide if the disparity in respect of 
these points be greater than normal, and it is not 
always easy to come at once to a decision. From the 
want of a proper appreciation of the several points 
of disparity in health, it is not uncommon for an 
erroneous diagnosis of phthisis to be based thereon. 
Appreciating the normal points of disparity, it is 
obviously easier to determine that the several direct 
signs of incipient phthisis are present at the left than 
at the right summit; relative dulness on percussion, 
broncho-vesicular or weakened respiration, increased 
vocal resonance, whisper, and fremitus, at the left 
summit are, of course, always abnormal. 

Corroborative evidence of incipient phthisis may 
be obtained by the presence of accessory signs. These 
are: (1) Fine bubbling or the so-called subcrepitant 
rale at the summit on one side. This sign denotes a 
circumscribed capillary bronchitis, and this, at the 
summit on one side, is usually associated with phthisis. 
(2) A crepitant rale at the summit on one side 
denotes a circumscribed pneumonia which is usually 
secondary to phthisis. (3) A pleuritic friction-sound 
limited to the summit on one side is evidence of 
a dry circumscribed pleurisy which occurs often in 
the early stage of phthisis. (4) Indeterminate rales, 
crumpling and crackling, are significant of phthisis 



PHTHISIS 217 

if limited to the summit on one side. These rales, 
it is to be recollected, are sometimes found in healthy 
persons on forced breathing, especially if the binaural 
stethoscope be employed. If they be normal they are 
found on both sides. The accessory signs are not 
sufficient for a postive diagnosis if they exist alone; 
but they are to be considered as corroborating the 
evidence derived from the direct signs, together 
with the symptoms and history. It is of service 
often in bringing out the rales to cause the patient 
to cough. 

As regards differential diagnosis, the affections 
with which incipient phthisis is likely to be con- 
founded are chronic bronchitis and moderate em- 
physema. With respect to the first of these affec- 
tions — namely, bronchitis — the differentiation must 
depend on the presence or the absence of positive 
signs of phthisis; in other words, phthisis is either 
diagnosticated or excluded. The physical signs in 
cases of moderate emphysema sometimes lead to 
the error of supposing this affection to be phthisis. 
Owing to the relatively greater intensity of the reso- 
nance on percussion at the left summit, dulness is 
thought to exist at the right summit, and a prolonged 
expiration, with the normally greater vocal resonance 
at the right summit, are regarded as signs of phthisis. 
This error may be avoided by a careful study of the 
signs of emphysema and the normal disparity in respi- 
ration, vocal resonance, and fremitus, existing between 
the two sides of the chest. 

The physical diagnosis of a phthisical affection 



218 DISEASES OF THE RESPIRATORY ORGANS 

which is considerable or moderate in amount, is, in 
most cases, an easy problem. Inspection often fur- 
nishes marked signs. The upper anterior portion 
of the chest on one side is depressed or flattened, 
and the superior costal movements of respiration are 
diminished, the chest elsewhere being symmetrical in 
both size and motions. There is more or less marked 
dulness on percussion at the upper part of the chest 
on the affected side. Sometimes the diminished reso- 
nance is tympanitic in quality (tympanitic dulness) 
without the existence of cavities, the resonance being 
transmitted from the primary and secondary bron- 
chial tubes. The respiration is either bronchial or 
broncho-vesicular approximating more or less to the 
bronchial. Occasionally, however, the respiratory 
sounds are too feeble for their characters to be appre- 
ciated. There is either bronchophony, or the vocal 
resonance is notably increased without the broncho- 
phonic characters. The whisper is either distinctly 
bronchophonic or it is notably increased in intensity, 
high in pitch, and tubular in quality. Vocal fremitus 
is often increased. Moist bronchial rales, coarse or 
fine, are generally present. With these diagnostic 
signs on one side, the signs of a smaller amount of 
disease are generally present on the other side. 

In some cases of a moderate phthisical affection, 
the judgment may be confused by the resonance on 
percussion being increased or vesiculotympanitic 
on the affected side. This sign denotes the coex- 
istence of emphysematous lobules (vicarious emphy- 
sema) developed in the progress of phthisis. The 



FIBROID PHTHISIS 219 

diagnosis of the latter affection is then to be based 
on the signs obtained by auscultation. 

In advanced phthisis the physical diagnosis of the 
disease is easy. The signs distinctive of this stage 
of the disease are those which denote pulmonary 
cavities — namely, tympanitic resonance on percus- 
sion within a circumscribed space; cracked metal or 
amphoric resonance; cavernous respiration; cavernous 
whisper and sometimes pectoriloquy; amphoric 
respiration and voice, and gurgling (vide Chapter V 
for description of these signs) . 

The cavernous signs are generally associated with 
the signs of solidification. In some cases, however, 
in which the disease has been non-progressive and 
retrogressive, the cavernous signs are present with- 
out the signs which denote solidification of lung. 



FIBROID PHTHISIS— INTERSTITIAL PNEUMONIA, 
OR CIRRHOSIS OF LUNG 

In this affection the physical conditions are, solidi- 
fication from hyperplasia of the interstitial pulmonary 
tissue, dilatation of bronchial tubes (bronchiectasis), 
and diminished volume of the lung affected. The 
affection, as a rule, is either limited to or especially 
marked on one side. The whole of a lung, or only 
a portion of it, may be affected. Bronchitis always 
coexists. 

There is notable dulness on percussion, the dim- 



220 DISEASES OF THE RESPIRATORY ORGANS 

inished resonance being sometimes tympanitic. The 
degree of resonance may vary at different examinations, 
owing to differences in the amount of morbid products 
within the bronchial tubes. The respiration is bron- 
chial, or broncho-vesicular. At times, from obstruc- 
tion of bronchial tubes, it may be suppressed. Bron- 
chophony and increased vocal resonance are the 
vocal signs, together with the corresponding whisper- 
ing signs. The side of the chest which is chiefly or 
exclusively affected becomes contracted either entirely 
or in part, resembling in this respect the appearances 
after chronic pleurisy. 

With these signs the affection is to be differen- 
tiated from the ordinary form of phthisis, by reference 
to points pertaining to the symptoms and history. 



DIAPHRAGMATIC HERNIA 

The presence of more or less of the abdominal 
viscera within the thoracic cavity in consequence of 
a congenital deficiency of a portion of the diaphragm, 
or perforation from accidents, or enlargement of the 
natural openings, gives rise to certain anomalous 
signs — namely, a tympanitic resonance, variable at 
different times owing to differences as regards the 
quantity of gas within the viscera; absence of the 
respiratory murmur from the base of the chest upward, 
the height proportional to the space occupied by the 
abdominal organs, and the intestinal sounds emanating 
from within the chest, not conducted from below. 






DIAPHRAGMATIC HERNIA 221 

This extremely rare affection can only be con- 
founded with pneumothorax or a pleural effusion, when 
the stomach is full of food. 

The use of the x-ray is invaluable in this condition, 
and gives positive evidence as to the physical relations 
of the diaphragm, and the abdominal, and thoracic 
viscera. 



CHAPTER VII 

THE PHYSICAL CONDITIONS OF THE HEART 
IN HEALTH AND DISEASE. THE HEART- 
SOUNDS AND CARDIAC MURMURS 

Physical conditions of the heart in health : Boundaries of the 
precordia — Normal situation of the apex-beat — Boundaries 
of the deep and of the superficial cardiac space — Relations of 
the aorta and the pulmonary artery to the walls of the chest — 
The heart-sounds — Characters distinguishing the first and the 
second sound — Mechanism of the production of the heart- 
sounds — Auscultation of the pulmonic and the aortic second 
sound separately — Movements of the auricles and ventricles 
in relation to each other — Physical conditions of the heart in 
disease: Enlargement of the heart — Hypertrophy and dilata- 
tion — Abnormal impulses of the heart, and modifications of the 
apex-beat — Valvular lesions — Roughness of the pericardial 
surfaces — Liquid within the pericardial sac — Abnormal modifica- 
tions of the heart sounds — Reduplication of heart-sounds — 
The pulse — Frequency of pulse — Regularity of pulse — Size of 
pulse — Rapidity of pulse — Tension" of pulse — Character of 
arterial wall — Capillary pulsation — Pulsation of the cervical 
veins — Cardiac murmurs— Normal and abnormal blood currents 
within the heart, and their relations with the heart-sounds — 
Mitral direct murmur — Mitrafi regurgitant murmur — Mitral 
systolic non-regurgitant, or intra-ventricular murmur — Aortic 
direct murmur — Aortic regurgitant murmur — Aortic dias- 
tolic non-regurgitant murmur — Coexisting endocardial mur- 
murs — Tricuspid direct murmur — Tricuspid regurgitant mur- 
mur — Pulmonic direct murmur — Pulmonic regurgitant murmur 
— Facts of practical importance in relation to endocardial 
murmurs — Pericardial or friction murmur. 

Before entering upon the study of the physical 
diagnosis of the diseases of 'the heart, the student 



THE PRECORDIA 223 

must be familiar with its anatomy and physiology. 
For a description of the structure and functions of 
this organ, he is referred to anatomical and physio- 
logical treatises. The plan of this work embraces 
the anatomical relations of the heart and the space 
which it occupies within the chest, as physical con- 
ditions of health determinable by normal signs, to- 
gether with the heart-sounds. Having briefly stated 
these conditions of health, the morbid physical con- 
ditions which may be ascertained by percussion, 
auscultation, and other methods of physical explora- 
tion, will be considered. The latter heading will 
include an account of the cardiac murmurs. 



THE PHYSICAL CONDITIONS OF THE HEART 
IN HEALTH 

The Precordia. — The Superficial and the Deep Cardiac 
Space. — The area on the surface of the chest corre- 
sponding to the space which the heart occupies within 
the chest, is the precordial region, or the precordia. 
The upper, lower, and two lateral boundaries of this 
region must be memorized. The upper boundary is 
the third rib, the lower is a horizontal line passing 
through the fifth intercostal space; the left lateral 
boundary is at or a little within the left mid-clavicular 
line, and the right lateral boundary is represented by a 
vertical line situated about a finger's breadth to the 
right of the right margin of the sternum. As the 
volume of the heart varies, within certain limits, in 



224 PHYSICAL CONDITIONS OF THE HEART 

different healthy persons, the boundaries of the pre- 
cordia are, of course, not always exactly the same. 
The foregoing statements are sufficiently accurate for 
practical purposes. 

The horizontal line representing the lower bound- 
ary of the precordia intersects the point where the 
apex-beat of the heart is felt. The normal situation 
of the apex-beat must be recollected. In most healthy 
persons the apex-beat is felt in the fifth intercostal 
space, a little within the mid-clavicular line. This 
is assuming the persons to be sitting or standing; 
in recumbency on the back the beat sometimes rises 
to the fourth intercostal space, and it is sometimes 
found in the fourth space in the sitting or standing 
position of the body. The distance from the mid- 
clavicular line varies in different healthy persons; 
it is sufficiently accurate to say it is a little within 
that line (Fig. 9). 

In changing a patient from the left lateral recum- 
bent to the right lateral position it may be determined 
by palpation and percussion that the apex of the heart 
moves a half to one and a half inches to the right in 
healthy people. 

The use of the orthodiagraph^ method of examin- 
ing the heart in action, has brought about a read- 
justment of our ideas as to the probable accuracy 
of topographical percussion of the heart. Although 
percussion will still be considered a necessary and 
useful method of examining the heart, the highest 
standard of accuracy will demand the use of the 
orthodiagram. 



THE PRECORDIA 



225 



The force of the apex-beat varies much in different 
healthy persons, owing to other causes than the power 
of the heart's action, such as the amount of muscular 
substance and fat in that situation, the width of the 



Fig. 9 




:' ' e 



intercostal space, the convexity of the chest, the rela- 
tion to the left lung, etc. Allowance is to be made 
for these variations in determining the abnormal 
modifications of the force of the beat, which belong 
among the physical signs of disease. 
15 



226 PHYSICAL CONDITIONS OF THE HEART 

Within a portion of the precordia the heart is uncov- 
ered of lung, and in the remaining portion lung inter- 
venes between the heart and the walls of the chest. 
The former of these portions is called the superficial 
and the latter is called the deep cardiac space. The 

Fig. 10 




deep cardiac space on the right side extends to the 
median line. On the left side the lung recedes at a 
point on the median line on a level with the cartilage 
of the fourth rib, and the anterior border of the upper 
lobe makes an outward curve, returning inward at 



THE PRECORDIA 227 

or near the apex of the heart. This leaves the heart 
uncovered within an area which, for practical purposes, 
may be represented by a right-angled triangle, the 
hypotenuse extending from the median line on a 
level with the costal cartilage of the fourth rib to the 
apex of the heart; the right angle formed by the median 
line and the horizontal line which forms the lower 
boundary of the precordia (Figs. 9 and 10). 

The limits of the superficial cardiac space may be 
easily defined by percussion. It is only necessary to 
ascertain the curved line formed by the receding 
anterior border of the upper lobe of the left lung. 
A distinct, although not great, dulness on percussion 
marks this border of the lung. The border of the 
lung is as distinctly marked by the abrupt diminu- 
tion of the vocal resonance, if auscultation be made 
with the stethoscope. The outer boundaries of the 
deep cardiac space may also be determined by per- 
cussion; distinct, although slight dulness marks the 
limits of the precordia. Defining thus the bound- 
aries of the precordia and of the superficial cardiac 
space in healthy persons, makes a good practical 
exercise in percussion. Distinct though slight dulness 
may usually be made out in the fourth space to the 
right of the sternum as far as three-quarters of an inch 
from the sternal border. 

Relations of the Aorta and Pulmonary Artery to the 
Wall of the Chest. — The base of the heart, especially 
in connection with auscultatory signs, is generally 
considered to be at the second intercostal space near 
the sternum, this situation being, in reality, just 



228 PHYSICAL CONDITIONS OF THE HEART 

above the base. In this situation sounds produced 
at the aortic and the pulmonic orifice are best studied, 
either in health or disease. With reference to these 
sounds, the anatomical relations of the aorta and the 
pulmonary artery to the right and the left second 
intercostal space are of importance. If the stetho- 
scope be applied in the second intercostal space on 
the right side, close to the sternum, it is very near 
the aorta, and sounds produced at the aortic orifice 
are best heard in this situation. If the stethoscope 
be applied in the second intercostal space on the left 
side, it is very near the pulmonary artery, and the 
sounds produced at the pulmonic orifice are best 
heard in this situation. Reference will be made to 
these two situations in giving an account of the heart- 
sounds in health and disease, and of adventitious 
sounds or murmurs (Fig. 9). 

The Heart-sounds. — It is customary to consider the 
heart-sounds as two in number, and to distinguish 
them as the first, or systolic, and the second, or 
diastolic, sound. The characters which distinguish 
the heart-sounds in health are to be studied prepar- 
atory to the study of the abnormal modifications 
which are important physical signs of disease. It is 
essential to be able always to make the distinction 
practically between the so-called first, or systolic, 
and the second, or diastolic, sound in order to connect 
with them separately cardiac murmurs. The con- 
ventional use of the term heart-sounds, as distin- 
guished from cardiac murmurs, must be borne in mind. 
The cardiac murmurs are adventitious sounds; they 



THE HEART-SOUNDS 229 

are never merely abnormal modifications of the 
heart-sounds, but they are new sounds added to or 
replacing these. 

Considering the heart-sounds as two in number, 
namely, the first, or systolic, and the second, or dia- 
stolic, these follow in a certain rhythmical order, 
and, in health, this suffices for the recognition of 
each. It answers all practical purposes to say that 
the sounds follow each other after an interval which 
is just appreciable, this interval being the short pause 
of the heart. After the occurrence of both, an interval 
is readily appreciable, called the long pause of the 
heart. It is not necessary to carry in the memory 
the exact relative duration of each of the two sounds 
and each of the two intervals. The fractions of a 
unit, in fact, do not express the length of the sounds 
and intervals as correctly as less definite expressions, 
inasmuch as the figures represent only the mean of 
variations within the limits of health. It is sufficiently 
exact to say that, with the ear or stethoscope applied 
over the situation of the apex-beat, the systolic sound 
is longer than the diastolic, louder, lower in pitch, and 
has a quality which may be called booming. Per 
contra, the diastolic sound is shorter, weaker, higher 
in pitch, and has a quality which may be called val- 
vular or clicking. Aside from the relative length, the 
other characters are more or less marked in different 
healthy persons. 

A third heart-sound is heard at the apex in about 
65 per cent, of people under forty when they are placed 
in the recumbent and left lateral positions. This 



230 PHYSICAL CONDITIONS OF THE HEART 

heart-sound which is softer and of lower pitch than 
the second sound, occurs early in diastole and follows 
the second sound of the heart by about one-tenth to 
two-tenths seconds. This sound seems to be due to 
the sudden tension of the auriculo-ventricular valves, 
as a result of the first rush of blood from auricle into 
ventricle, in diastole (vide Thayer, Arch. Int. Med., 
1909, vol. iv, No. 4). 

These distinctive characters of the systolic and 
diastolic heart-sounds are apparent when the ear or 
stethoscope is applied over the apex. At the base 
of the heart, that is, in the second intercostal space 
near the sternum, the characters of the systolic sound 
are not the same as over the apex. The diastolic 
sound in this situation is louder than the systolic. 
The latter is said to be accentuated at the base, the 
systolic sound being accentuated at the apex. More- 
over, the systolic at the base may not be longer than 
the diastolic; it loses more or less of its booming quality, 
the pitch remaining lower than that of the diastolic 
sound. Removing the ear or the stethoscope a cer- 
tain distance from the apex in any direction, occasions 
similar changes in the characters of the systolic sound. 
The interposition of several thicknesses of a napkin 
has the same effect. 

From the differential characters over the apex, and 
the rhythm alone in other situations, there is no diffi- 
culty in distinguishing the systolic from the diastolic 
sound in health. In cases of disease, however, owing 
to disturbance of the rhythm, modifications of the 
characters of the systolic sound, and the absence 



THE HEART-SOUNDS 231 

sometimes of one of the sounds, other means of recog- 
nition must be resorted to. If the apex-beat can be 
felt, this offers a ready way for recognizing the systolic 
sound — the sound which is synchronous with the apex- 
beat is, of course, the systolic sound. This mode 
is not always available, inasmuch as the apex-beat 
cannot always be felt. Another mode is always avail- 
able — namely, feeling the carotid pulse. The carotid 
pulse is synchronous with the systolic sound, whereas 
there is a slight interval between this sound and the 
radial pulse. 

The student is aided in comprehending certain 
physical signs by taking into view the mechanism of 
the production of the heart-sounds. The diastolic 
sound is produced by the sudden forcible closure of 
the aortic and the pulmonic valves. This closure is 
caused by a retrograde movement of the columns of 
blood in the aorta and pulmonary artery, directly the 
ventricular systole is ended. The retrograde move- 
ment is due to the recoil of the coats of the arteries 
which have been dilated by the column of blood 
moving onward during the ventricular systole. This 
recoil causes regurgitation into the ventricle when 
either the aortic or the pulmonic valve is rendered 
incompetent by lesions. 

The mechanism of the systolic sound is less simple. 
This sound is in part due to the forcible tension 
of the auriculo-ventricular valves, caused by the 
systole of the ventricles. In this way is produced 
a valvular element of the systolic sound. That the 
impulsion of the heart against the walls of the chest 



232 PHYSICAL CONDITIONS OF THE HEART 

furnishes another element, seems demonstrable. To 
this element of impulsion the systolic sound is indebted 
for its greater intensity, as compared with the diastolic 
sound, its length, and its booming quality. This is 
shown by the fact, already stated, that when ausculta- 
tion is made at a certain distance from the apex, these 
characters are eliminated, and by the fact that dis- 
eases which diminish or arrest the impulsion move- 
ments of the heart produce the same modifications. 
The valvular element of the systolic sound is weaker 
than the diastolic sound, a fact which at first occa- 
sions surprise when the difference in size between the 
aortic and pulmonic and the auriculo-ventricular 
valves is considered. 

The explanation of this apparent incongruity is as 
follows: The aortic and pulmonic segments at the 
end of the ventricular systole are in contact with 
the arterial walls, and are expanded when the recoil 
of the latter follows. On the other hand, when the 
ventricular systole takes place in health, the auri- 
culo-ventricular valves are not in contact with the 
walls of the ventricles, but they are floated out, and 
the orifices are nearly or quite closed; the movement 
of the blood, therefore, in the systole only renders 
these valves tense. The diastolic sound, in other words, 
is due to the expansion of the sigmoid valves of the 
aorta and pulmonary artery, whereas, the valvular 
element of the systolic sound is due to tension of the 
auriculo-ventricular valves. 

With reference to important bearing on ausculta- 
tion in disease, the diastolic or second sound is to be 



THE HEART-SOUNDS 233 

studied as produced at the aortic and the pulmonic 
orifices separately. Recalling the anatomical rela- 
tions of the aorta and the pulmonary artery to the 
wall of the chest, if the stethoscope be applied in 
the second intercostal space on the right side close 
to the sternum, the characters of the diastolic sound 
are derived chiefly from the aortic valve, and if the 
stethoscope be applied in the second intercostal space 
on the left side close to the sternum, the characters 
of the diastolic sound are derived chiefly from the 
pulmonic valve. The correctness of this statement is 
proved by differences in the characters of the sound 
on two sides in health, and by the modification in 
cases of disease. These morbid modifications will 
enter into the physical diagnosis of cardiac affections. 
In health the aortic diastolic sound is somewhat 
louder, higher in pitch, and the valvular quality more 
marked than the pulmonic diastolic sound. 

In patients under twenty years of age, the pulmonary 
second sound may be found to be equal to, or louder 
than the aortic second sound. Over the age of twenty, 
and usually to an increasing degree with advancing 
years, the aortic second sound is louder than the pul- 
monary second sound, owing, in all probability, in the 
main, to the increasing tension or blood pressure in 
the systemic arteries at maturity and after. 

The student should verify these points of difference 
by the study of the diastolic sound in the two situations 
just named. In order for the comparison to be a 
fair one in health, and available in the diagnosis of 
disease, the normal anatomical relations to the wall 



234 PHYSICAL CONDITIONS OF THE HEART 

of the chest, of the aorta, and pulmonary artery must 
be preserved. These relations are affected by changes 
in the symmetry of the chest, and sometimes by 
enlargement of the heart. The lungs must also be free 
from disease; otherwise, the transmission of the sounds 
will be abnormal. 

In the account of the mechanism of the production 
of the heart-sounds (vide page 231), it was stated that 
the first or systolic sound consists of a valvular ele- 
ment and an element of impulsion. This valvular 
element is a twofold sound, that is, it is a combina- 
tion of a sound produced by the mitral and a sound 
produced by the tricuspid valve. These two synchro- 
nous valvular sounds may be studied separately in 
health, and their abnormal modifications constitute 
important diagnostic signs in cases of disease. 

The two valvular sounds may be designated the 
mitral and the tricuspid systolic sounds. Adding to 
these two sounds, the sound of impulsion produced 
by the movements of the apex, with the ventricular 
systole, are three distinct sounds. The diastolic or 
second sound of the heart, as has been seen, is resolv- 
able into two distinct sounds. Hence, the number 
of distinct heart-sounds is, in reality, five, two of 
which are diastolic and three systolic — namely, the 
mitral valvular, the tricuspid valvular, the sound of 
impulsion, the aortic, and the pulmonic' Each of 
these five sounds may be studied separately in health 
and disease. The abnormal modifications of each 
furnish important information in diagnosis. 

In health, the sound of impulsion is heard over 



THE HEART-SOUNDS 235 

the situation of the apex-beat of the heart. The mitral 
valvular sound is studied by listening with the stetho- 
scope applied to the left of the apex at a distance 
sufficient to eliminate the sound of impulsion. 

The tricuspid valvular sound is heard best at the 
end of the sternum or just to the left of this point. 

In the pages which follow I shall sometimes refer to 
the systolic and the diastolic sound in the singular 
number, it being understood that the systolic sound 
embraces three, and the diastolic two, components; 
and at other times I shall refer to the sounds sepa- 
rately, which are combined in the two sounds. 

The order of the succession of the movements of 
the auricles and of the ventricles is to be kept in mind, 
with reference to the comprehension of certain phy- 
sical signs of disease. Points of special importance 
are the contraction of the auricles in the latter part 
of the long pause of the heart, preceding the ventric- 
ular systole, and the twisting of the heart from left 
to right in the systole, this movement being reversed 
in the diastole. In these systolic and diastolic twist- 
ing movements the visceral and parietal portions of 
the pericardium move upon each other, in health 
noiselessly, owing to their smoothness and moisture. 

The movements occasion an auscultatory sign — 
namely, a friction murmur — w T hen the surfaces are 
roughened by the presence of lymph. Other points are, 
the size of the pericardial sac, that is, its capability 
of holding when filled, but not dilated, from fifteen to 
twenty ounces of liquid, and its attachment, not to the 
base of the heart, but to the vessels above the base. 



236 PHYSICAL CONDITIONS OF THE HEART 



PHYSICAL CONDITIONS OF THE HEART IN 
DISEASE 

The physical conditions of the heart in disease, 
which are determinable by physical exploration, are, 
(1) enlargement of the heart; (2) abnormal impulses 
and modifications of the apex-beat; (3) valvular 
lesions; (4) roughness of the pericardial surfaces; 
and (5) liquid within the pericardial sac. Having 
considered these conditions, an account of abnormal 
modifications of the heart-sounds and cardiac murmurs 
will conclude this chapter. 

Enlargement of the Heart. — Enlargement of the heart 
may be slight, moderate, great, or very great, these 
terms expressing different degrees of enlargement 
with sufficient precision for clinical purposes. In 
cases of very great enlargement, the space within 
the chest which the heart occupies may be from four 
to five times larger than in health. The situation 
of the base of the heart remains but little, or not at 
all, changed in cases of enlargement; the increased 
space which the heart occupies is therefore down- 
ward. The increased space extends much more to 
the left than to the right; the left border of the heart, 
in proportion to the enlargement, is carried beyond the 
mid-clavicular line on the left side, whereas, the right 
border is carried comparatively but little beyond the 
normal right lateral boundary of the precordia even 
when the enlargement is very great. 

The cardiac dulness may be increased in all directions 



ENLARGEMENT OF THE HEART 237 

or only in one direction. We naturally attribute a 
dislocation of the left border of cardiac dulness to 
the left, to enlargement of the left ventricle; a dislo- 
cation of the right border to the right, to enlargement 
of the right ventricle; an increase upward, to dilata- 
tion of the auricles or of the great vessels. Cardiac 
dulness may be found as far to the right of the sternum 
in the third and fourth spaces, in dilatation of the right 
auricle and ventricle in tricuspid insufficiency, as it 
is found normally to the left of the sternum. 

The superficial cardiac space is enlarged in propor- 
tion to the enlargement of the heart; the organ pushes 
to the left the receding anterior border of the upper 
lobe of the left lung, and is proportionately in contact, 
uncovered of lung, with the wall of the chest. The 
apex of the heart is lowered in proportion to the 
enlargement, and it is carried more or less to the left 
of its normal situation. It may be lowered to the 
sixth, seventh, eighth, or ninth intercostal space. The 
enlargement of the heart is rarely equal in all its 
parts. The ventricular enlargement may be entirely, 
or chiefly, of either the right or the left ventricle. 
Enlargement of the right ventricle tends to carry the 
right side of the heart more to the right than when 
the left ventricle is enlarged. The situation of the 
apex is also affected by the parts of the heart in which 
the enlargement predominates. The apex is carried 
farther to the left of its normal situation, other things 
being equal, when the enlargement predominates on 
the right side of the heart; and it is lowered, without 
being carried far to the left, when the enlargement of 



238 PHYSICAL CONDITIONS OF THE HEART 

the left ventricle predominates. The apex of the 
organ, in cases of considerable, or of great enlargement, 
becomes changed in form; it is rounded or blunted. 
This change is most marked when enlargement of 
the right ventricle predominates. All these points 
are of importance with reference to the comprehen- 
sion of the physical signs of enlargement of the heart. 

Enlargement of the heart may be due, entirely 
either to hypertrophy or to dilatation (simple hyper- 
trophy and simple dilatation) . If, however, the enlarge- 
ment be sufficient to occasion notable disturbance of 
the circulation, both these forms of enlargement are 
combined, but, as a rule, one or the other form pre- 
dominating, so that, of the cases of diseases of the 
heart which come under medical treatment, the ma- 
jority are cases of either enlargement with predomi- 
nant hypertrophy, or enlargement with predominant 
dilatation. 

These widely different physical conditions are 
concerned especially in the abnormal impulses and 
modifications of the apex-beat, as well as, also, the 
heart-sounds. 

Abnormal Impulses of the Heart, and Modifications of 
the Apex-beat. — The abnormal situation of the apex 
of the heart when enlarged has been stated. Gen- 
erally the situation is determinable by the apex-beat. 
It has been seen that in health the beat is sometimes 
not appreciable by the touch, owing to the thickness 
of the soft parts, and the conformation of the thorax, 
and, for these reasons, the force of the beat varies 
much in different healthy persons. Exclusive of 



ABNORMAL IMPULSES OF THE HEART 239 

normal variations, the beat is generally strong and 
prolonged, in proportion as the heart is enlarged by 
hypertrophy. There are exceptions to this state- 
ment, which are to be explained by the altered form 
of the apex; when it loses its pointed form it does 
not so readily come into contact with the walls of 
the chest in an intercostal space, and, hence, the 
beat may be weak although the ventricular systole 
be abnormally strong. On the other hand, the apex- 
beat is weakened by dilatation, and it may be want- 
ing, as a result of diminished strength of the systole 
of the ventricles. The apex-beat is also abnormally 
weak in fatty degeneration and softening of the heart, 
as well as in functional debility of the organ, incident 
to other diseases than those of the heart. 

If there be considerable or great enlargement, the 
heart being in contact with the w r all of the chest 
over a larger area than in health, impulses other 
than the apex-beat are generally apparent to the eye 
and touch. Not frequently impulses are appreciable 
in each intercostal space between the situation of the 
apex and the base of the heart. These abnormal 
impulses are felt to be strong in proportion as the 
enlargement is due to hypertrophy, and weak in pro- 
portion as dilatation predominates. Enlargement 
seated in the right ventricle causes an impulse in the 
epigastrium which is strong or weak in proportion 
as hypertrophy or dilatation predominates. Cardiac 
impulses are felt and seen in abnormal situations 
when the heart is removed from its normal situation 
by the pressure of an aneurism, or other tumor, by 



240 PHYSICAL CONDITIONS OF THE HEART 

pleuritic effusion, hydroperitoneum, etc. The error of 
mistaking for a cardiac impulse the pulsation of an 
aneurismal tumor is to be avoided. Another error is 
to be avoided — namely, mistaking abnormal impulses 
due to the heart being uncovered of lung, from shrink- 
ing of the latter in certain pulmonary affections, for 
impulses denoting enlargement of the heart. In cases 
of enlargement by hypertrophy, a heaving movement of 
the whole precordia is sometimes felt when the hand 
is applied to the chest. A violent shock is sometimes 
felt by the hand applied to the precordia, but with- 
out a sense of increased muscular power, in cases of 
purely functional disorders of the heart. Because of 
pericardial adhesions, or due to enlargement and dis- 
placement of the heart, a systolic retraction may be 
seen where we should expect a systolic impulse, and a 
diastolic impulse or retraction may appear, and demand 
close attention to be located with reference to its 
place in the cardiac cycle. 

Valvular Lesions. — The lesions affecting the valves 
of the heart are of a varied character, for an account 
of which the student is referred to treatises on car- 
diac diseases, or on pathological anatomy. It suffices 
here to consider that, with reference to physical signs 
and pathological effects, they may be distributed into 
three groups, as follows: (1) Lesions which diminish 
more or less the size of the orifices, or obstructive 
lesions; (2) lesions which render the valves more or 
less incompetent and permit regurgitation, or regurgita- 
tive lesions; and (3) lesions which roughen the sur- 
faces over which the blood moves without occasioning 






LIQUID WITHIN THE PERICARDIAL SAC 241 

either obstruction or regurgitation. The latter may 
be distinguished as innocuous lesions, giving rise to no 
pathological effects although represented by cardiac 
murmurs. 

It is to be borne in mind that in the great majority 
of cases valvular lesions are seated in the left side of 
the heart, that is, they are either mitral or aortic. 
Tricuspid and pulmonic lesions are comparatively 
rare, and they are generally congenital. Not infre- 
quently mitral and aortic lesions coexist, and there 
may be coexisting lesions at all the orifices of the 
heart. 

Valvular lesions are represented by cardiac mur- 
murs. By means of the murmurs the existence of 
lesions is known, their situation at the different orifices 
may be ascertained, and, generally, it is practicable 
to determine whether they occasion obstruction or 
regurgitation, or both. These several points of inquiry 
will be considered presently under the heading Cardiac 
Murmurs, and in connection with the lesions of the 
different valves respectively in the next chapter. 

Roughness of the Pericardial Surfaces. — In place of 
the smoothness of the pericardial surfaces in health, 
which permits their movements upon each other 
noiselessly, the presence of the inflammatory product, 
lymph, and, in some rare instances, morbid growths, 
occasion an adventitious sound or murmurs, which will 
be noticed in connection with other murmurs, and as 
entering into the physical diagnosis of pericarditis. 

Liquid within the Pericardial Sac. — More or less liquid 
transudes into the pericardial sac in cases of general 
16 



242 PHYSICAL CONDITIONS OF THE HEART 

dropsy or anasarca, but rarely in very large quantity. 
Liquid effusion occurs in acute pericarditis, and in 
this affection the sac may become filled with serous 
or purulent liquid. In some cases of chronic peri- 
carditis the sac is greatly dilated by liquid, the 
quantity amounting to four pounds, or even more. 

When the pericardial sac is filled with liquid, with- 
out being dilated, it forms a pyriform tumor within 
the chest, the base of which is at the sixth or seventh 
intercostal space; the apex rises nearly to the sternal 
notch; the left lateral border is considerably beyond 
the nipple, and the right lateral border is more or 
less beyond the right margin of the precordia. The 
anterior portion of the filled pericardium is mostly 
uncovered of lung and in contact with the wall of 
the chest. Within this area there is either notable 
dulness or flatness on percussion, together with absence 
of respiratory murmur and of vocal resonance. By 
means of these signs, the boundaries of the pyriform 
tumor may be readily delineated on the surface of 
the chest. The difference in form and situation of 
the area of dulness or flatness on percussion in cases 
of large pericardial effusion, from the area in cases of 
enlargement of the heart (vide page 236), is to be noted 
and borne in mind with reference to the differential 
diagnosis. 

When the pericardial sac is partially filled with 
liquid, the same signs are present, but within an 
area of less extent, and the configuration of the pyri- 
form tumor is wanting. 

In cases of chronic pericarditis with a large accu- 



MODIFICATIONS OF THE HEART-SOUNDS 243 

mutation of liquid, the pericardial sac is dilated so 
that its lateral boundaries may extend nearly to the 
axillary and infra-axillary regions, and the pyriform 
shape is usually lacking, the outline being more nearly 
globular. Under these circumstances, flatness on per- 
cussion, absence of respiratory murmur and of vocal 
resonance, are present over the greater part of the 
anterior aspect of the chest. 



ABNORMAL MODIFICATIONS OF THE HEART- 
SOUNDS 

In order to appreciate the abnormal modifications 
of the heart-sounds, their normal characters are to 
be kept in mind (vide page 228), and the student 
must be practically familiar with them. The modi- 
fications relate to the three components of the systolic 
sound, and to the two components of the diastolic 
sound, collectively and separately. 

The sound of impulsion, as heard over the apex, 
is intensified in hypertrophy of the heart. This 
sound is not only notably loud, but prolonged, and 
its booming quality is marked. It sometimes has a 
ringing tone, called tinnitus. The systolic valvular 
sounds — namely, the mitral and the tricuspid — are 
also more or less increased in intensity. The increased 
intensity of either the mitral, or the tricuspid valvular 
sound, separately, denotes that the hypertrophy is 
seated especially in either the left or the right ventricle. 

In some cases of violent palpitation the systolic 



244 PHYSICAL CONDITIONS OF THE HEART 

sounds are notably intensified, the sound of impulsion 
being comparatively weak. I suppose the explana- 
tion to be as follows: the ventricles contract with a 
kind of spasmodic action upon a small quantity of 
blood; and, under these circumstances, the auriculo- 
ventricular valves, not being floated out as they are 
when the ventricles are well filled, expand with force 
in the ventricular systole, instead of being merely 
made tense, as in health. Hence, the valvular sounds 
are intensified, while the sound of impulsion may be 
feeble or wanting. The sound of impulsion over the 
apex is weakened or lost, as an effect of those affec- 
tions of the heart, which diminish the power of the 
ventricular systole. These affections are enlargement 
from dilatation, atrophy, fatty degeneration, myo- 
carditis, obstruction of the coronary arteries, and 
softening. The systolic valvular sounds are also 
more or less weakened, but in a less degree than the 
sound of impulsion. The loss of the sound of impulsion 
over the apex renders the so-called first, or systolic 
sound of the heart, short and valvular in quality. 

Liquid effusion within the pericardium renders the 
sound of impulsion over the apex more or less weak. 
If the liquid effusion be large, only the systolic val- 
vular sounds — namely, the mitral and tricuspid — are 
appreciable. Diminished power of the heart's action 
from other than cardiac diseases, involves weakness 
of all the heart-sounds, but more especially of the 
sound of impulsion. 

Abnormal modifications of the diastolic sound re- 
late to the aortic and pulmonic sounds considered 






MODIFICATIONS OF THE HEART-SOUNDS 245 

separately. Bearing in mind the mode of interro- 
gating the aortic and the pulmonic orifice with refer- 
ence to the valvular sound derived from each inde- 
pendently of the other (vide page 233), a comparison 
of the two sounds in diseases of the heart affords often 
useful information. Whenever, from mitral obstruc- 
tive or regurgitant lesions, or both combined, or from 
obstruction at the aortic orifice, the quantity of blood 
propelled by the left ventricle into the aorta is 
diminished, the recoil of the arterial coats, after 
the ventricular systole, is lessened; consequently, the 
aortic segments expand with less force, and the aortic 
sound is weakened. Diminished intensity of the 
aortic sound thus represents an abnormal diminution 
of the quantity of blood propelled into the systemic 
arteries by the systole of the left ventricle, and this 
diminished intensity of sound is, in a measure, a 
criterion of the amount of mitral obstruction or mitral 
regurgitation, or both combined, or of aortic obstruc- 
tion. In some cases of great obstruction or regurgita- 
tion the aortic sound is completely suppressed. How 
is weakening of this sound to be determined and 
measured? By comparison w T ith the pulmonic sound. 
Now, as will presently appear, the pulmonic sound 
is often intensified when the aortic sound is weakened. 
Hence, the former is not an accurate standard for 
this comparison; but it suffices for an approximation 
to accuracy. In cases of hypertrophy of the left 
ventricle without obstruction, or regurgitant valvular 
lesions, the aortic sound is abnormally intensified, 
owing to increased arterial blood pressure, which is, 



246 PHYSICAL CONDITIONS OF THE HEART 

in most instances, secondary to fibroid, or atrophic, 
lesions of the kidneys. Intensification of the aortic 
sound may be due to increased tension in the systemic 
arteries without cardiac hypertrophy. 

A simpler cause of weakening or suppression of the 
aortic sound, is damage from lesions of the aortic 
valve. In proportion as the function of this valve is 
impaired by lesions, the intensity of the sound is 
diminished, and if the function of the valve be lost, 
the sound is wanting. In these cases, the pulmonic 
sound being but little or not at all affected, it is an 
accurate standard for the comparison. 

The pulmonic sound is weakened in the rare in- 
stances of lesions affecting the pulmonic valve. This 
sound is oftener intensified than weakened. It is 
notably intensified when the right ventricle is hyper- 
trophied, and especially when this hypertrophy is 
associated with dilatation of the left auricle resulting 
from mitral obstruction or regurgitation. These 
lesions weakening, as has just been seen, the aortic 
sound, the contrast between the aortic and the pul- 
monic sound in some cases of mitral lesions is very 
marked. The pulmonic sound is sometimes loud, 
while the aortic sound is suppressed. 

Increased tension of the pulmonary arterial system 
may increase the intensity of the pulmonic sound, 
irrespective of hypertrophy of the right ventricle. 
This increased tension is due to whatever cause 
obstructs the pulmonary circuit, i. e., whatever puts 
obstruction in the way of the right ventricle whether 
this be obstructed or regurgitated blood at the mitral 



MODIFICATIONS OF THE HEART-SOUNDS 247 

orifice, paralysis of the left auricle, or mechanical 
obstruction of the pulmonary veins, capillaries, or 
arteries in the lung as the result of consolidation, 
fibrosis, bronchial spasm, emphysema or defective 
expansion of the thorax. The pulmonary second 
sound is also intensified in cases of palpitation and 
excitation of the heart by exercise and emotion. 

In comparing the aortic and the pulmonic sound 
in disease, as in health, it is to be assumed that the 
anatomical relations of the aortic and the pulmonary 
artery to the second intercostal space on either side, 
close to the sternum, are not materially altered, and 
that the lungs are free from lesions, in consequence 
of which the conduction of the sound on either side 
is abnormal. 

Returning to the systolic group of sounds, the 
mitral and the tricuspid sound may be studied sepa- 
rately. With the stethoscope applied at or a little to 
the left of the apex, the valvular sound which is heard, 
is derived from the mitral valve. On the other hand, 
if the stethoscope be applied at, or to the left of, the 
end of the sternum, the valvular sound is derived 
from the tricuspid valve. Notable weakness or sup- 
pression of the mitral sound, as compared with the 
tricuspid, represents impairment of the function of 
the mitral valve, and, per contra, notable weakness, 
or suppression of the tricuspid sound, denotes impair- 
ment of the function of the tricuspid valve. Allow- 
ance, in this comparison, is to be made for a normal 
disparity, the mitral sound being louder than the 
tricuspid in health. 



248 PHYSICAL CONDITIONS OF THE HEART 

Reduplication of Heart-sounds. — The sounds of the 
heart are said to be reduplicated, when either the 
systolic or the diastolic sounds are repeated, or when 
both occur twice, before the long pause or interval. 
Considering the heart-sounds as twofold, that is, 
systolic and diastolic, and as represented by the 
whispered words Lub-dup, reduplication of the systolic 
sound is expressed by Lublub-dup, of the diastolic 
by Lub-dupdup, and of both by Lublub-dupdup. 

Clinically, reduplication of the diastolic is observed 
much more frequently than reduplication of the sys- 
tolic sound. In other words, the pulmonic and aortic 
sounds, instead of being synchronous, occur in succes- 
sion. This may occur when the systolic sounds occur 
synchronously. The explanation is, that from in- 
creased tension of either the systemic or the pulmonic 
arteries (oftener the latter), the recoil of the arterial 
coats after the systole, and the extension of the sigmoid 
valves, take place, in one artery sooner than in the 
other. If both the systolic and the diastolic sounds 
be reduplicated, the explanation which seems most 
rational is, that the tw T o ventricles contract, not in 
exact unison, but that one contracts a little before 
the other. In systolic reduplication the mitral and 
the tricuspid sounds occur in succession, instead of 
occurring synchronously. The sound of impulsion is 
not reduplicated. 

There is a form of functional disorder which may 
be confounded with reduplication of both sounds of 
the heart. In this disorder, with every alternate 
revolution of the heart, the sounds are weak, and 



THE PULSE 249 

the ventricular systole is not represented by a radial 
pulse, the force of the contraction of the ventricle 
being insufficient to cause an appreciable pulsation 
in the remote arteries; hence, the heart-sounds occur 
twice for each pulse at the wrist. Under these cir- 
cumstances, however, the carotid pulse may generally, 
if not always, be felt with the weak, as well as with 
the stronger, ventricular contraction, and in this way 
the error of confounding the disorder with reduplica- 
tion may be avoided. The type of arrhythmia here 
described is now know^n to be due to extra-systole, 
i. e., the ventricles of the heart alone participate in an 
extra contraction, which can be heard, and gives a 
palpable pulse wave or not according to the strength 
of the contraction. 

Reduplication of the heart-sounds may occur in 
connection with cardiac lesions, or there may be no 
evidence of any organic affection. In the latter case 
the anomaly falls properly among the varied forms 
of functional disorder of the heart. Whether, or 
not, it be connected with lesions, it has no important 
pathological significance. It is usually of temporary 
duration. 

THE PULSE 

An examination of the arterial pulse is an essential 
in every examination of a patient. We note its occur- 
rence at various parts of the body, in the temporals, 
carotids, brachials, radials, femorals, popliteals, and 
in the dorsalis pedis. We observe its comparative 



250 PHYSICAL CONDITIONS OF THE HEART 

qualities on the two sides of the body. We pay par- 
ticular attention to its characteristics at the radial 
or brachial in each arm. It is taken for granted that 
the student understands fully the rather complex 
neuro-muscular mechanism, which determines the 
incidence and rate of cardiac contractions, and the 
laws of hemo-dynamics, which determine the various 
characters of the venous and arterial pulses at the 
periphery. For full information the student is referred 
to recent special works on the heart and pulse. 

Frequency. — We note the frequency of the pulse in 
the minute, observing variations from the physio- 
logical limits, according to the age of the patient. 
An infrequent pulse may follow great bodily exertion, 
convalescence from severe diseases, malnutrition, in 
vomiting, during vagus stimulation, in cerebral com- 
pression, and in aortic stenosis alone among the val- 
vular defects of the heart. 

If the auricles of the heart beat two, three, or more 
times as often as the ventricles (heart-block), we note 
the lack of relation by combined auscultation and 
palpation; or by observing the auricular venous 
pulse in the neck, while palpating the carotid, or radial 
artery, or the apex beat. A particularly slow pulse 
may occur during the physiological effect of digitalis. 

If the pulse be markedly irregular, its frequency 
may be decidedly less than the frequency of the ven- 
tricular contractions. In this case, auscultation of 
the heart sounds, or palpation of the apex beat, 
should always be combined with palpation of the 
radial pulse. The difference between the ventricular 



THE PULSE 251 

rate and the radial pulse rate is spoken of as the 
pulse deficit. Followed from day to day, the record 
of the pulse deficit gives valuable evidence of the 
effect of treatment in improving the efficiency of the 
ventricles. 

Inequality in the size and force of pulse beats neces- 
sarily accompanies irregularity in the intervals which 
separate them, a long diastolic interval being followed 
by a large pulse-wave, and a short interval by a small 
pulse-wave. 

The exact study of the irregularities of the pulse 
has become of great practical importance. For their 
complete recognition, tracings of the arterial and 
venous pulses, or records of the electrical changes 
accompanying cardiac contraction, are necessary, 
although the main distinctions may be made by the 
finger (vide Chapter XII). 

A frequent pulse may be due to muscular activity, 
exhausting diseases, and debilitated states. It is 
almost always found in fever, in vagus paralysis, 
in the last stage of cerebral pressure or basilar 
meningitis, in neurotic and toxic states, and in 
exophthalmic goitre, and as an important sign of weak 
heart muscle, in almost all cardiac, valvular defects 
when compensation is failing and w^here there is 
vaso-motor paresis, or collapse. Excessive frequency, 
occurring in attacks, may be observed at intervals for 
years, usually without apparent cause (paroxysmal 
tachycardia) . 

Regularity. — We note the regularity of the pulse, as 
affecting its force and frequency. 



252 PHYSICAL CONDITIONS OF THE HEART 

The irregularities of the pulse are as follows : 

1. Complete loss of the dominant rhythm, the inter- 
vals being wholly irregular, and the beats unequal. 
This is called the perpetually irregular pulse, and is 
usually characterized by excessive frequency as well. 
It indicates complete failure of the normal auricular 
contractions, the auricles being in the state called 
fibrillation. The jugular venous pulse is always sys- 
tolic in time. This type of irregularity may persist 
for years, but always denotes serious damage to the 
heart muscle. Among the valvular defects, it is most 
commonly found with mitral obstruction. 

2. Occasional interruption of a regular pulse by 
premature heart-beats, usually single, rarely in groups. 
Such premature heart-beats are called extra-systoles. 
They may occur at long intervals, or as often as every 
other beat. When the latter, the rhythm is called 
bigeminy, or coupled-beats, a condition characteristic 
of the early toxic effect of digitalis. Extra-systoles 
are not in themselves of serious significance. Occa- 
sional extra-systoles are common toxic results of 
tobacco, coffee, and other poisons. They occur in 
severe fatigue, in persons with high blood-pressure, 
and without evident cause. 

3. Occasional complete omission of a heart-beat, 
the true intermittent pulse. If the first heart-sound is 
also absent, this indicates a temporary heart-block, 
and is seen also during the use of digitalis. If there 
is a first heart-sound, but no radial pulse, it indicates 
an extra-systole which was not of sufficient force to 
open the aortic valve. 



THE PULSE 253 

4. Occasional sudden change from a normal rhythm 
to a regular rhythm of approximately double the rate, 
the rapid rhythm being maintained for a few beats, to 
hours or even days, and usually returning abruptly to 
the previous normal rate. This is true paroxysmal 
tachycardia. 

5. Moderate variation in the rate of the dominant 
rhythm, synchronous with respiration, is normal in 
children and in many adults. This is called the respi- 
ratory irregularity, or sinus arrhythmia, as it depends 
upon the varying rate of discharge of impulses from 
the sinus node, the normal pace-maker of the heart. 
Similar variation in the dominant rhythm occurs in 
excitement, and may be marked in meningitis. It is 
due to stimuli received by the heart through the 
vagus nerves, and never signifies disease of the heart 
muscle. 

6. Alternation of large and small beats, without 
noticeable variation in the intervals which separate 
them, constitutes the alternating pulse. It is to be 
carefully distinguished from bigeminy, for it signifies 
serious exhaustion of the contractile power of the 
heart muscle. 

Inspiration may cause decrease in the size and 
frequency of the pulse, in cases of inflammations and 
tumors of the mediastinum (pulsus paradoxus) . 

Inequality of force upon the two sides may be due 
to abnormalities in the size of the arteries upon one 
side, or to pressure as by an aneurism of the aorta. 

Size. — We note the size of the pulse. The pulse is 
large or small according to the amount of blood deliv- 



254 PHYSICAL CONDITIONS OF THE HEART 

ered to the great vessels during ventricular systole, 
as modified by the condition of tonus of the vessels, 
between the heart and the point of palpation of the 
artery. We find a large pulse often in hypertrophy of 
the left ventricles, especially in aortic regurgitation, 
in compensated high blood pressure of nephritic origin, 
and often in the sthenic stage of fevers. We find the 
pulse small in syncopal attacks, in cardiac muscular 
weakness, in stenosis of any cardiac valvular orifice, 
particularly in mitral and aortic stenosis, and during 
chills. 

Rapidity. — We note the rapidity with which the pulse 
fills and empties (or the celerity). We find a quick 
pulse in the collapsible pulse of aortic insufficiency 
(the water-hammer or Corrigan pulse), and where we 
have a relaxed arterial wall at the same time that the 
heart is overacting, as in the asthenic stage of fevers. 
We have a slow pulse in aortic stenosis, and where we 
have high peripheral resistance and no disturbance of 
the reflex nervous control of the heart. 

Tension. — We note the sense of resistance or tension 
of the pulse as appreciated by applying the tips of 
three fingers to the artery, and noting the pressure 
needed at the proximal finger to prevent the apprecia- 
tion of the pulse by the distal finger. Although we 
may get a general impression of the tension by palpa- 
tion, this is a matter so easily determinable, and so 
exactly, both for the systolic and diastolic phase of 
the pulse, by the use of apparatus for estimating blood 
pressure, that this method should supplement the 
manual palpation wherever possible. 



THE PULSE 255 

A hard pulse is with difficulty obliterated by digital 
pressure. Nephritis of the chronic type and advanced 
arteriosclerosis usually exhibit a hard pulse. 

A soft or easily compressible pulse is found in fever, 
anemia, weakness of the heart muscle, and in vaso- 
motor paresis. 

Character of Arterial Wall. — We note the character 
of the arterial wall, i. e., whether the arterial wall 
is palpable or not, when the pulse is obliterated by 
pressure farther up the arm. The normal radial artery 
is not palpable when empty. A firmly contracted 
artery is to be distinguished from an artery with an 
hypertrophy of its muscular wall, and both of these 
conditions from a smooth fibrous replacement in the 
wall, or, what is easier, from the so-called pipe-stem 
artery with nodular calcareous deposits. These are 
appreciated by rolling the vessel under the finger tips, 
or the edge of the nails. 

Capillary Pulsation. — The capillaries may show sys- 
tolic pulsation in aortic regurgitation. This may be 
seen as a faint pulsation if a microscope slide be pressed 
against the muco-cutaneous margin of the lower lip, 
just hard enough to blanch the skin, or if the end of 
the nail is bent, to the point of blanching the pulp 
beneath, or in the systolic flushing of a line drawn 
across the forehead by the finger. 

Pulsation of the Cervical Veins. — A systolic pulsation 
is normally seen in the majority of people in the 
external jugular veins for about three-quarters to 
an inch above the clavicle. The impulse is seen best 
on the right side, and is synchronous with auricular 



256 PHYSICAL CONDITIONS OF THE HEART 

contraction. The pulsation in the veins is visible, but 
very rarely appreciable by the touch. It is to be dis- 
tinguished from pulsation of the arteries of the neck. 
This is easily done by finding that pressure just above 
the clavicle, sufficient to interrupt the flow of blood 
in the veins, but not in the arteries, abolishes the 
pulsation. A venous pulse when excessive is generally 
due to a tricuspid regurgitant current, and is there- 
fore caused by the contraction of the right ventricle. 
If caused by the contraction of the right ventricle 
in tricuspid regurgitation, the venous pulse is 
synchronous with the carotid pulse, the systolic 
sounds of the heart, and the apex-beat. If caused by 
the contraction of the right auricle, the venous pulse 
precedes the carotid pulse; it is presystolic. A venous 
pulse, thus, may be either ventricular or auricular, 
and the differentiation is easily made. There may 
be both a ventricular and an auricular venous pulse, 
the one synchronous with, and the other preceding, 
the carotid pulse. Pulsation is sometimes observed 
in other veins than those of the neck — the brachial, 
femoral, and even veins still more remote from the 
heart. 

CARDIAC MURMURS 

All adventitious abnormal sounds which are added 
to the heart-sounds, are embraced by the term cardiac 
murmurs. Let it be borne in mind that, conven- 
tionally, the murmurs are never abnormal modifica- 
tions of the heart-sounds, but always newly produced 
sounds, and they always represent morbid conditions 



CARDIAC MURMURS 257 

of either the heart or the blood. When due to morbid 
conditions of the blood, they are called inorganic, 
anemic, or hemic murmurs, and when they represent 
valvular lesions or changes within the heart, they are 
distinguished as organic murmurs. 

In fevers, as of the acute infectious diseases, or in 
high temperature from various other causes, we com- 
monly find a systolic murmur at the apex correspond- 
ing to the murmur of mitral regurgitation. This may 
be heard also in marked anemia and in extreme asthenia, 
and this murmur may properly be called a functional 
murmur, as it seems to be due to an atonic or relaxed 
condition of the mitral ring, and to a lack of proper 
functioning of the papillary muscles. 

A systolic murmur heard over the base of the heart, 
especially at the second left interspace, seems to be 
due to a dilatation of the conus arteriosus, and is found 
to occur not infrequently in fever, and anemias, and 
from unexplained causes. 

In healthy adults there is, not uncommonly, during 
expiration, a systolic murmur heard over the base of 
the heart, and disappearing during inspiration. This 
is usually more easily heard in those with flat chests. 
It is rather common in children. The important dis- 
tinguishing point about this murmur is its dependence 
upon the expiratory phase of respiration. Its causation 
is not well understood. 

There are other accidental murmurs, usually systolic, 
but occurring also in any part of the cardiac cycle, 
of which the cause is uncertain and the importance 
negligible. 
17 



258 PHYSICAL CONDITIONS OF THE HEART 

The murmurs may be distributed into three groups 
after differences in quality, namely: (1) soft; (2) rough; 
and (3) musical murmurs. The soft murmurs resemble 
the sound produced by air from the nozzle of a pair 
of bellows, and, hence, are often called bellows mur- 
murs. Murmurs are said to be rough when their 
qualities may be expressed by such terms as rasping, 
grating, creaking, croaking, etc. They are called 
musical when the sound is a musical note. The bel- 
lows murmurs are the most frequent, and the musical 
are more rare than the rough murmurs. The quality 
of a murmur does not in general invest it with any 
special pathological or diagnostic significance. The 
murmurs vary in pitch, being either relatively high or 
low. The variations in pitch are useful in aiding to 
discriminate different coexisting murmurs. 

This account of murmurs applies to those produced 
at the orifices or within the cavities of the heart. 
They are distinguished as endocardial murmurs. 
Adventitious sounds are, however, produced upon 
the external surface of the heart. These constitute 
exocardial, pericardial, or friction murmurs. 

Endocardial murmurs are produced by blood- 
currents pursuing either a normal or an abnormal 
direction. With a familiar knowledge of these cur- 
rents, and of their relations with the heart-sounds, 
the several endocardial murmurs are very easily under- 
stood, as regards points involved in their differentia- 
tion from each other. The student is, therefore, advised 
first to become acquainted with the blood-currents 
in health and in disease. Directing the attention to 



CARDIAC MURMURS 259 

the left side of the heart, there are two normal blood- 
currents — namely, the current from the left auricle 
to the left ventricle, and the current from the left 
ventricle into the aorta. These may be distinguished 
as the direct currents. The first is the mitral direct 
current, and the second is the aortic direct current. 
Two abnormal currents may occur in the left side of 
the heart. These currents can only take place when 
the valves are rendered incompetent by lesions. The 
incompetency of the valves allows of regurgitation, 
and these abnormal currents may be distinguished as 
the regurgitant currents. One of these is a current 
backward from the left ventricle into the left auricle, 
owing to incompetency of the mitral valve; this is 
the mitral regurgitant current. The other is a current 
backward from the aorta into the left ventricle, 
arising from incompetency of the aortic valve; this 
is the aortic regurgitant current (Figs. 11 and 12). ^ 

What are the relations of the four currents in the 
left side of the heart with the heart-sounds? The 
mitral direct current takes place when the auricles 
contract. The contraction of the auricles precedes 
the ventricular systole. The ventricular systole is 
synchronous with the systolic sounds of the heart. 
The mitral direct current, therefore, takes place just 
before these sounds. It begins after the diastolic 
sounds, and continues until it is suddenly and com- 
pletely arrested by the contraction of the ventricle. 
It is, therefore, presystolic. It is obvious that the 
current cannot continue during the ventricular con- 
traction, that is, when the first systolic sounds of the 



2(50 PHYSICAL CONDITIONS OF THE HEART 

Fig. 11 




Diagram representing the normal blood-currents. 

Plain arrows represent currents in right side of heart. Dotted arrows represent 

currents in left side of heart. 




Diagram representing the abnormal blood-currents. 

Plain arrows represent currents in right side of r^eart. Dotted arrows represent 

currents in left side of heart. 



CARDIAC MURMURS 261 

heart are produced. The mitral regurgitant current 
is caused by the contraction of the ventricle; the 
currrent, therefore, must take place with the systolic 
sounds of the heart. The aortic direct current, being 
caused by the contraction of the left ventricle, takes 
place with the systolic sounds of the heart. It is, 
therefore, coincident with the mitral regurgitant 
current. The aortic regurgitant current is caused 
by the recoil of the arterial coats upon the column of 
blood within the aorta, directly after the ventricular 
systole, and as this recoil causes the diastolic aortic 
sound of the heart, the current and this sound must 
be coincident or the diastolic aortic sound is wholly 
replaced by the sound of the regurgitant current. 

Recapitulating the relations of the four currents 
with the heart-sounds, the aortic direct and the mitral 
regurgitant take place with the systolic sounds — they 
are systolic currents. The mitral direct current 
precedes the systolic sounds — it is presystolic; and 
the aortic regurgitant current takes place with the 
diastolic sound — it is diastolic. 

Analogous blood-currents take place in the right 
side of the heart, and have corresponding relations 
with the heart-sounds. These currents are the tri- 
cuspid direct, the tricuspid regurgitant, the pulmonic 
direct, and the pulmonic regurgitant. The pulmonic 
regurgitant is exceedingly rare in consequence of the 
infrequency of pulmonic lesions; but the tricuspid 
regurgitant is not uncommon, and occurs without 
valvular lesions or enlargement of the heart when the 
right ventricle is distended with blood, constituting 



262 PHYSICAL CONDITIONS OF THE HEART 

what has been called the "safety valve function" of 
the tricuspid orifice. 

Organic endocardial murmurs are produced by 
the foregoing direct and regurgitant blood-currents, 
and they are designated by the same names, that is, 
they are either direct or regurgitant. Thus, there 
are produced in the left side of the heart — the side 
in which valvular lesions are seated in the great 
majority of cases — a mitral direct murmur, a mitral 
regurgitant murmur, an aortic direct murmur, and 
an aortic regurgitant murmur. In the right side of 
the heart there may be produced corresponding mur- 
murs — namely, a tricuspid direct, a tricuspid regurgi- 
tant, a pulmonic direct, and a pulmonic regurgitant. 
It remains to point out the means of differentiating 
these several murmurs, aside from their relations with 
the heart-sounds. 

Mitral Direct or Presystolic Murmur. — This murmur 
begins after the diastolic sounds and ends abruptly 
with the systolic sounds. Almost invariably, this 
murmur is rough in quality; occasionally, it is a soft 
bellows murmur. When rough, it is often quite loud. 
The rough quality is peculiar; it is suggestive of vibra- 
tion, and may be imitated by causing the lips or the 
tongue to vibrate with the breath in expiration. I 
state the mechansim of this murmur, inasmuch as 
the explanation is original with me, and has not been 
as yet generally accepted. It is caused by the vibra- 
tions of the mitral curtains, and takes place when 
these curtains are united at their sides, leaving a 
narrow buttonhole-like orifice through which the 



CARDIAC MURMURS 263 

mitral direct current of blood flows. Throwing the 
lips into vibration with the breath, represents not only 
the characteristic quality of the murmur, but the 
mode of its production. The physical conditions 
which are requisite generally for its production are a 
narrowed mitral orifice, and flaccidity of the mitral 
curtains. The latter of these conditions does not 
always exist in cases of mitral obstructive lesions, 
and, hence, the murmur by no means always accom- 
panies the.se lesions. When it is considered how loud 
a blubbering sound may be produced by the vibration 
of the lips with a feeble current of air, it is not difficult 
to understand that an intense murmur may be caused 
by a current of blood propelled by the comparatively 
weak contraction of the auricle. This murmur may 
be produced artificially, and the mechanism of its 
production demonstrated in the following manner: 
Take a small India-rubber bag with thin walls — such 
as that which, when inflated, makes a balloon for 
children; attach the opening to the efferent tube of 
a Davidson's syringe; make a small orifice opposite 
to the attached opening of the bag; immerse the bag 
in a basin of water, and then force a current of water 
into the bag. With a binaural stethoscope, the pec- 
toral extremity applied lightly to the bag, a murmur 
caused by the flow of water from the bag into the 
basin, is heard, resembling as closely as possible the 
usual presystolic murmur. 

A mitral direct murmur may be produced without 
mitral lesions, the murmur having the same char- 
acteristic quality as when lesions exist, and being 



264 PHYSICAL CONDITIONS OF THE HEART 

also quite loud. This fact, based on clincial proof, 
was stated by rne many years since, together with 
the explanation. The murmur occurs when there 
are aortic lesions which permit regurgitation. Under 
these circumstances, at the time when the auricular 
contraction takes place, the left ventricle is already 
filled with blood, the mitral curtains are floated out 
so as to be in contact with each other, and the mitral 
direct current passing between the curtains throws 
them into vibration precisely as when the orifice is 
narrowed. The vibration of the lips when lightly 
in contact, caused by the expired breath, illustrates 
the manner in which a mitral direct murmur takes 
place without mitral lesions. The murmur thus 
occurring without mitral lesions is not constant; it 
is now present and now absent, depending, as it does, 
on the quantity of blood within the left ventricle at 
the time of the contraction of the auricle. It follows 
from what has just been stated, that a mitral direct 
murmur is not always a sign of mitral obstructive 
lesions when there is free aortic regurgitation. (This 
murmur is commonly recognized in the United States 
as the Flint murmur.) 

This murmur is limited to a circumscribed space 
around the apex of the heart. However loud the mur- 
mur may be in this situation, it is usually lost within 
a short distance of the apex, although in rare instances 
it may be heard over the lower part of the left scapula. 1 

1 For further diagnostic and explanatory details of the Flint 
murmur the reader is referred to an article by Thayer in Amer. 
Jour. Med. Sci., 1901, cxxii, No. 6. 



CARDIAC MURMURS 265 

A mitral direct murmur is never due to a morbid 
condition of the blood. Although it occurs without 
mitral lesions, vet, inasmuch as its occurrence then 
requires the existence of aortic regurgitant lesions, it 
cannot be said to be an inorganic murmur. A mitral 
direct murmur may occur in adherent pericardium 
(chronic fibrous pericarditis), and in large hearts with- 
out valvular lesions; in the latter the accessory signs 
of mitral stenosis are lacking. 

A mitral direct murmur, as has been stated, does 
not always accompany mitral lesions. If the mitral 
curtains are fixed or made rigid by calcification, so 
that vibration with the mitral direct current of blood 
does not take place, either the murmur is wanting, 
or its usual characteristic quality is absent. Feeble- 
ness of the auricular contraction, from dilatation or 
overdistention of the auricle with blood, may cause 
the murmur to disappear. Under these circum- 
stances the murmur may be sometimes present and 
at other times absent. Cardiac vibration or thrill 
is a physical sign w T hich accompanies often a well- 
marked characteristic presystolic murmur, but this 
sign may occur in connection with other valvular 
lesions. The thrill is presystolic in time when it 
accompanies the presystolic murmur. The thrill is 
systolic when it accompanies an aortic direct or a 
mitral regurgitant murmur, and diastolic when it 
accompanies an aortic regurgitant murmur. 

Mitral Diastolic Murmur. — A murmur may be pro- 
duced by the mitral direct current of blood prior to 
the contraction of the left auricle; in other words, 



266 PHYSICAL CONDITIONS OF THE HEART 

occurring before the presystolic murmur. From the 
latter this murmur may be distinguished as a mitral 
diastolic murmur. The flow of blood from the auricle 
into the ventricle begins directly the ventricular 
systole ends. This may be said to be a passive cur- 
rent until the auricle contracts. The contraction of 
the auricle makes the current active. Now, under 
certain organic conditions, the passive current pro- 
duces a murmur which, in point of time, is diastolic, 
that is, directly following the diastolic sounds of the 
heart. The murmur occurs at the same time as an 
aortic regurgitant murmur. From the latter it is to 
be discriminated by its localization at or near the apex 
of the heart, and by the absence of a diastolic murmur 
at the base. It may precede the characteristic pre- 
systolic murmur, differing from the latter in quality; 
or the diastolic murmur, without the characteristics 
which usually belong to the presystolic murmur, may 
continue during the whole of the long pause of the 
heart. 

The mitral diastolic murmur (as this murmur may 
be called) is doubtless rare, but less so, perhaps, than 
may be supposed, for two reasons: (1) It is apt to 
be overlooked; and (2) when recognized it has been 
customary to refer it to the aortic orifice. The fre- 
quency of the murmur and the particular physical 
conditions under which it is present are to be deter- 
mined by further clinical study. It is apparent that 
in mitral stenosis owing to the differences in the size 
of the opening, the flexibility of the cusps, the volume 
of blood and the force of the auricular contraction 



CARDIAC MURMURS 267 

we may have an absence of any murmur, or most 
commonly a presystolic murmur, or less often a 
murmur which may occupy any point of time between 
the systolic sound and the diastolic sound of the 
heart, i. e., a diastolic, or meso-diastolic, or diastolic- 
presystolic murmur. 

Mitral Regurgitant Murmur — Mitral Systolic Non- 
regurgitant, or Intra-ventricular Murmur. — The mitral 
regurgitant murmur, synchronous with the systolic 
sounds, that is, a systolic murmur, may be soft, rough, 
or musical in quality, its intensity and pitch being 
variable. Aside from its relation with the systolic 
heart-sounds, it is distinguished by having its maxi- 
mum of intensity at or near the situation of the apex- 
beat. It may be limited to a circumscribed area, and 
if heard at a distance from the apex it is best trans- 
mitted laterally round the left side of the chest, on 
the line of the apex. It is often heard on the posterior 
aspect of the chest near the lower angle of the left 
scapula, and not infrequently in the corresponding 
situation on the right side. 

A murmur with the systolic sounds of the heart, 
heard within a limited area at the apex, may be due 
to roughness of the endocardial membrane without 
mitral incompetency, and, consequently, without a 
mitral regurgitant current. This is a mitral systolic 
non-regurgitant murmur. It may, also, be called an 
intra-ventricular murmur, being produced, not at 
the mitral orifice, but within the ventricle. This 
murmur cannot always be discriminated from a 
feeble mitral regurgitant murmur. If, however, a 



268 PHYSICAL CONDITIONS OF THE HEART 

mitral murmur be conducted laterally for some dis- 
tance to the left of the apex, and if it be heard on 
the back, it probably denotes mitral regurgitation. A 
mitral systolic, non-regurgitant, or intra-ventricular 
murmur is the murmur present in endocarditis. It 
may be caused by a tendinous cord extending from 
the inner wall on one side to the opposite side of the 
ventricular cavity. This occurs as a congenital anom- 
aly. Aneurism of the heart may be so situated as 
to give rise to a murmur simulating a mitral systolic 
murmur. Cardiac aneurysm, however, is exceedingly 
rare. Aneurysm of the thoracic aorta may cause a 
murmur which, transmitted through the heart, sim- 
ulates a mitral systolic murmur. 

The impulse of the apex of the heart against the 
adjacent portion of the lung sometimes forces the air 
from the air-vesicles sufficiently to give rise to a blow- 
ing sound occurring with each ventricular systole. This 
is liable to be confounded with an endocardial mur- 
mur. Produced in the way just stated, it is heard only 
during the act of inspiration, and especially at the 
end of this act. 

A mitral systolic murmur is rarely, if ever, due to 
an abnormal condition of the blood, without any 
anatomical change in the orifice or endocardial mem- 
brane. Conditions of the blood, however, which 
are favorable for the production of inorganic mur- 
murs may intensify this murmur, as well as any of the 
organic murmurs. 

It has been conjectured that a mitral systolic 
murmur may be produced by a purely functional 



CARDIAC MURMURS 269 

incompetency of the mitral valve, permitting a mitral 
regurgitant current, no actual lesion of the valve or the 
mitral orifice existing. In this way are explained the 
occurrence of a mitral systolic murmur and its dis- 
appearance without other evidence of endocarditis or 
any organic affection of the heart. It does not enter 
into the scope of this work to discuss the validity of 
this explanation. The fact, however, that a mitral 
systolic murmur may exist, continue for weeks or 
months, and even for years, and disappear, the murmur 
being neither accompanied nor followed by signs or 
symptoms denoting organic disease, is an important 
fact to be borne in mind with reference to diagnosis 
and prognosis. It is apparent from experimental 
studies as well as from clinical observation that a true 
mitral regurgitation, wdth the characteristic murmur 
so constantly associated when the valve cusps are 
diseased, may occur from any of several causes which 
permit of a relaxation of the constrictor ring of muscle 
which encircles the mitral orifice. Among the causes 
frequently recognized are, high temperature, acute 
endocarditis, with or without coexisting chorea, and 
any cause, either general (anemia) or local (myocar- 
ditis), which may interfere with the muscular compe- 
tence of the mitral ring. Strain of the heart muscle is 
apt to be a determining factor. Mitral incompetence 
from such lack of muscular efficiency is much more 
commonly accompanied by tricuspid incompetence 
than when the mitral leak is due to disease of the 
cusps themselves. 



270 PHYSICAL CONDITIONS OF THE HEART 

Aortic Direct Murmur. — This murmur, like the mitral 
systolic murmur, occurs with the systolic sounds of 
the heart. Of the organic murmurs on the left side 
of the heart, the mitral systolic murmur and the 
aortic direct murmur are synchronous, the others 
having different relations with the heart-sounds. 
The aortic direct murmur differs from the mitral 
systolic murmur in having its maximum of intensity 
at the base of the heart. It is loudest in the second 
intercostal space near the sternum. As a rule, it is 
louder in this intercostal space on the right than on 
the left side; this rule, however, has frequent excep- 
tions. It is transmitted better and farther, upward 
than downward. It is always heard over the carotid 
artery, and it is sometimes louder over this artery 
than at the base of the heart. As a murmur may be 
produced within the carotid artery, it is desirable to 
determine, when a systolic murmur is heard at the 
base, whether the carotid murmur is a transmitted 
murmur or not. This point is to be settled by com- 
paring the murmur over the carotid with the murmur 
at the base, as regards quality and pitch. If the 
quality and pitch of the murmur in the two situations 
be the same, it is fair to consider the murmur in the 
carotid as not produced within the artery, but con- 
ducted by the blood-current from the aortic orifice. 

An aortic direct murmur is frequently inorganic. 
It is to be considered as such when it is not asso- 
ciated with an aortic regurgitant murmur; when the 
heart is not enlarged; when anemia is shown by the 
presence of murmurs in the large arteries; and when 



CARDIAC MURMURS 271 

there is the venous hum 1 in the neck — these physical 
evidences of anemia being associated generally, not 
invariably, with pallor, and with symptoms pointing 
to impoverishment of the blood. Moreover, an in- 
organic murmur is very rarely rough, and it is vari- 
able in its occurrence, being at one time present and 
at another time absent, whereas, an organic murmur 
is, in general, constant. Associated with other evi- 
dence of anemia, an aortic direct murmur may, never- 
theless, be organic, but, under the differentiating 
circumstances just stated, the lesion represented by 
the murmur, if the murmur be organic, must be in- 
nocuous, so that it is not of great practical impor- 
tance to determine whether the murmur be or be not 
inorganic. 

Like the other organic murmurs, an aortic direct 
murmur varies in different cases in intensity, quality, 
and pitch. An organic aortic direct murmur, per se, 

1 To obtain the venous hum {bruit de diable), cause the patient 
to turn the head as far as practicable to the left, and apply the 
stethoscope to the neck on the right side, near the clavicle, behind 
the sterno-cleido-mastoid muscle. Press the stethoscope with 
different degrees of force before concluding that the murmur is 
wanting. The venous hum is continuous, and closely resembles 
the sound of the humming top. Gentle pressure, with the finger 
above the stethoscope, so as to interrupt the flow of blood in 
the veins, causes the murmur at once to cease. This fact is 
proof of its being a venous murmur. A systolic murmur heard 
with the stethoscope applied to the neck, is an arterial murmur, 
which may either be produced within the artery, or transmitted 
from the aortic orifice. An arterial and a venous murmur in the 
neck often coexist. One cause of error in determining the 
presence of a true venous hum is the common occurrence of a 
murmur in the vessels of the thyroid gland. 



272 PHYSICAL CONDITIONS OF THE HEART 

does not denote always aortic obstruction. It may 
be due simply to roughness of the membrane at or 
above the aortic orifice, or to dilatation of the aorta. 
Such evidence as these, whether attributed to rough- 
ness or to dilatation, are recognized as proof of inflam- 
mation of the aorta, almost without excep ion of 
syphilitic origin. 

Aortic Regurgitant Murmur — Aortic Diastolic Non- 
regurgitant Murmur, or a Prediastolic Murmur. — An 
aortic regurgitant murmur occurs with the second, 
diastolic, sound of the heart. It is almost always 
heard at the base of the heart, but, in some instances, 
when not appreciable at the base, it is heard a little 
below the base — namely, near the sternum on the 
left side on a level with the fourth costal cartilage. In 
some instances, however, the maximum of intensity 
is in a corresponding situation on the right side. In 
the latter situation it has generally its maximum of 
intensity. It is transmitted best in a downward 
direction, being often heard at the apex, and some- 
times considerably outside or external to this point 
(i. e., in the left axilla). It is never inorganic. It is 
usually not intense, low in pitch, and soft; but it may 
be loud, high, rough, or musical. 

The aortic diastolic murmur is sometimes heard 
better with the ear than through a stethoscope. 

A short murmur is sometimes produced by the 
retrograde movement of the blood-current within 
the aorta, the aortic valve being intact, and regurgi- 
tation, therefore, not taking place. This murmur is 
due to roughening of the lining membrane of the 



CARDIAC MURMURS 273 

aorta by atheroma or calcareous deposit, and it is 
always preceded by an aortic direct murmur. It 
occurs directly after the systole, and ends with the 
second sound. Although of such brief duration, it 
is distinctly recognizable and distinguished from the 
preceding aortic direct murmur. I have long been 
accustomed to demonstrate this murmur in private 
teaching, and have called it an aortic diastolic non- 
regurgitant murmur. A better name is a predias- 
tolic murmur. It cannot be said to have much prac- 
tical importance, inasmuch as the lesion giving rise 
to it is represented by the aortic direct murmur which 
precedes it. This murmur may be associated with a 
true regurgitant murmur. This is the explanation 
of a diastolic murmur which is rough before and soft 
after the aortic second sound. 

Coexisting Endocardial Murmurs. — The murmurs refer- 
able to the left side of the heart, which have been 
considered, are often found in combination; two or 
three may coexist, or all of them may be present. 
Moreover, with more or less of these murmurs may 
be associated murmurs referable to the right side of 
the heart. Having become familiar with their relations 
with the heart-sounds, and other points involved in their 
differentiation, it is not difficult to recognize them in 
combination. The mitral murmurs are not infrequently 
associated. The mitral direct, being presystolic, ends 
with the systolic sounds, and the mitral systolic or re- 
gurgitant begins with these sounds; the systolic sounds, 
as it were, divide these two murmurs. These murmurs 
almost invariably differ from each other in pitch and 
18 



274 PHYSICAL CONDITIONS OF THE HEART 

quality. The presence of both, in fact, assists, rather 
than obstructs, the recognition of each. The aortic 
direct and the aortic regurgitant murmur, also, are 
often associated. A murmur then accompanies the 
systolic and the diastolic sounds of the heart; the 
two murmurs follow in the same rhythmical order 
as the groups of heart-sounds. These murmurs, 
when associated, can only be confounded with peri- 
cardial friction-sounds. 

The combination of the aortic direct and the mitral 
systolic murmur, alone offers any difficulty. These 
two murmurs have the same relation with the heart- 
sounds; they are both systolic. How is it to be deter- 
mined, when a systolic murmur is heard both at the 
base and apex, whether a mitral murmur is trans- 
mitted to the base, or an aortic murmur is transmitted 
to the apex; in other words, how is it to be decided 
whether two murmurs are present or only one murmur? 
If these two murmurs coexist, generally the circum- 
stances which distinguish each separately can be ascer- 
tained. Thus, the aortic murmur is transmitted into 
the carotid artery, and the presence of that murmur 
is then established; the mitral regurgitant murmur is 
often transmitted laterally around the chest, or heard 
at the lower angle of the scapula, and then the pres- 
ence of that murmur is established. But there are 
additional points, namely, the murmur at the base, 
and that at the apex generally differ sufficiently in 
pitch or quality to render it evident that there are 
two murmurs; and generally at a situation in the 
precordia between the base and apex, both murmurs 



CARDIAC MURMURS 275 

may be either lost or become notably weakened. 
Attention to these points in most instances divests 
the problem of difficulty. 

Mitral and aortic lesions are often of a character 
to give rise to only one murmur at either of these 
orifices. A mitral direct murmur not infrequently 
is present without the mitral regurgitant, and the 
reverse of this is often found. So, either an aortic 
direct or an aortic regurgitant murmur may exist 
without the other. 

Tricuspid Direct Murmur. — The lesions which are 
requisite for this murmur very rarely occur at the 
tricuspid orifice; hence, this murmur is exceedingly 
rare. It is to be distinguished from the mitral direct 
murmur by its localization being, not at the apex, 
but at the right border of the heart. Mitral direct 
murmur is usually found to coexist with a tricuspid 
direct murmur, in which case a presystolic murmur, 
with the characteristic blubbering quality is heard at 
the apex and at the right side of the heart. 

Tricuspid Regurgitant Murmur. — This murmur is not 
of infrequent occurrence. Tricuspid regurgitation 
occurs often when the right ventricle is considerably 
dilated, without the existence of lesions of the valve. 
A tricuspid regurgitation current, however, does not 
invariably give rise to an appreciable murmur. 
When a ventricular venous pulse is found in the neck, 
or better still, if a systolic liver pulse is found, these 
help materially to establish a diagnosis of tricuspid 
regurgitation, when taken with the other signs. 

The tricuspid regurgitant murmur, of course, occurs 



276 PHYSICAL CONDITIONS OF THE HEART 

with the first or systolic sound, being systolic like 
the mitral regurgitant murmur, and the latter gener- 
ally coexists. It is distinguished from the mitral 
regurgitant by its localization at the right inferior 
margin of the heart, and its transmission to the right, 
rather than to the left. The coexistence of the mitral 
and the tricuspid regurgitant murmurs is determined 
by the differences in pitch and quality, between a 
systolic murmur at the apex, and at the right margin 
of the heart. A venous pulse, synchronous with the 
first sound of the heart, points to tricuspid regurgi- 
tation, and, although sometimes present without a 
tricuspid regurgitant murmur, when present, it is 
corroborative evidence of the latter. 

Pulmonic Direct Murmur. — A pulmonic direct mur- 
mur, if organic, is generally connected with con- 
genital lesions. The pulmonic direct and the aortic 
direct current of blood taking place at the same 
instant, the murmurs representing both are, of course, 
systolic. How is the pulmonic to be distinguished 
from the aortic direct murmur? The pulmonic mur- 
mur is heard in the left second intercostal space close 
to the sternum, but this is not very distinctive, inas- 
much as, not infrequently, the aortic murmur is loud- 
est in that situation. The essential point of distinction 
is this : the pulmonic direct murmur is not transmitted 
into the carotid artery, whereas, the aortic direct 
murmur is always thus transmitted. A systolic thrill, 
appreciated by firm palpation in the second left inter- 
space, is an important and fairly constant sign in 
pulmonary stenosis. If an aortic direct and a pulmonic 



CARDIAC MURMURS 277 

direct murmur coexist, both being organic, the combi- 
nation is to be ascertained by finding that the murmur 
in the second intercostal space on the right side differs 
from that on the left side in pitch or quality, suffi- 
ciently to show the presence of these murmurs, the 
one on the right side being transmitted to the carotid 
artery. 

An inorganic, or functional, pulmonic direct mur- 
mur is of frequent occurrence in cases of anemia. 
It is frequently associated with an inorganic aortic 
direct murmur, the presence of the two murmurs 
being evidenced by a difference in pitch. 

Pulmonic Regurgitant Murmur. — This murmur is 
exceedingly rare in consequence of the infrequency 
of pulmonic regurgitant lesions. It occurs, of course, 
like the aortic regurgitant, with the second or diastolic 
sound. Its presence can be determined, when other 
signs go to show the existence of pulmonic, and the 
absence of aortic lesions. This murmur may, however, 
occur without any lesion or deformity of the pulmonary 
valve cusps or of its orifice, under conditions similar 
to those which may determine an aortic regurgitant 
murmur — namely, such a state of increased blood 
pressure in the pulmonary artery, due to marked 
obstruction in the pulmonary vessels, as will cause a 
dilatation of the pulmonary orifice, and lack of apposi- 
tion of the semilunar cusps. This so-called murmur 
of high pressure in the pulmonary artery is commonly 
known as the Graham-Steell murmur. A pulmonic 
regurgitant murmur may occur from pressure upon the 
pulmonary artery from without. 



278 PHYSICAL CONDITIONS OF THE HEART 

Facts of practical importance in relation to the 
endocardial murmurs, are embraced in the following 
statements : 

The question as to a murmur being organic or inor- 
ganic, relates chiefly, if not entirely, to the aortic direct, 
the pulmonic direct, and the mitral regurgitant mur- 
mur, other murmurs being almost invariably organic. 

Associated signs and symptoms generally warrant a 
definite conclusion whether an aortic direct or pulmonic 
direct murmur be, or be not, organic, and under the 
circumstances which render it difficult to decide this 
question positively, a positive decision is not of much 
immediate practical consequence. 

Valvular lesions, whether obstructive, regurgitant, or 
innocuous, are so uniformly represented by murmur, 
in a compensating heart, that, as a rule, absence of 
lesions may be predicated on the absence of murmur. 
If, how r ever, the signs and symptoms of a decompen- 
sating heart are present, no conclusions should be 
drawn, from the presence or absence of murmurs, as 
to the existence or location of valvular lesions. 

With a practical knowledge of the different organic 
murmurs, the situation of lesions at either of the 
orifices of the heart, or their existence at two or more 
of these orifices, may be demonstratively determined. 

By means of the murmurs, with other signs, it 
may be determined demonstratively whether the 
lesions involve obstruction or regurgitation, or both, 
or, on the other hand, that they are, as regards im- 
mediate pathological effects, innocuous. 

The murmurs do not afford definite information 



CARDIAC MURMURS 279 

as to the amount of obstruction or regurgitation, in 
other words, as to the pathological importance or 
gravity of lesions when they are not innocuous. Xo 
positive conclusions on this point of view are to be 
drawn from the intensity of murmurs, their pitch, or 
their quality. As a rule, murmurs which are weak, 
more than those which are loud, represent grave 
lesions. 

Pericardial or Friction Murmur. — A pericardial or 
friction murmur is produced by the rubbing together 
of the surfaces of the pericardium in the systolic 
and diastolic movements of the heart. In the vast 
majority of the cases in which this murmur occurs, 
it denotes either the presence of recent lymph which 
renders the surfaces more or less adhesive, or rough- 
ening from lymph which has become dense and ad- 
herent; its diagnostic significance, therefore, relates 
almost exclusively to pericarditis. In this relation it 
is of great practical importance. 

This exocardial murmur is to be discriminated from 
the endocardial murmurs. The points involved in the 
discrimination are as follows : The murmur is double, 
that is, a murmur accompanies both the ventricular sys- 
tole and diastole. It can, therefore, only be confounded 
with an aortic direct and an aortic regurgitant murmur 
in combination. The quality of the murmur is sug- 
gestive of rubbing or friction. It is sometimes a feeble, 
grazing sound; in other instances it is loud and rough. 
When rough, the quality is expressed by such terms 
as rasping, grating, creaking, etc. Although accom- 
panying both the systolic and diastolic sounds of the 



280 PHYSICAL CONDITIONS OF THE HEART 

heart, it has not that uniform, fixed relation to these 
sounds which characterizes the aortic direct and the 
aortic regurgitant murmur; it is not in definite accord 
with the heart-sounds. Moreover, in intensity it 
varies with the successive movements of the heart, 
being louder with some revolutions than with others, 
in this regard differing notably from the endocardial 
murmurs. It is not heard without the precordia, as 
a rule, and is often limited to a part of the precordial 
region, whereas, certain of the endocardial murmurs 
namely — the mitral regurgitant and the aortic direct — 
are often heard at a considerable distance from the 
heart. Firm pressure with the stethoscope, and often 
a forced expiration, intensify the murmur. Its source 
seems very near the surface of the chest. In this 
respect it differs notably from endocardial murmurs, 
the latter appearing to come from a certain distance 
within the chest. This point of distinction is very 
appreciable, especially if, as often happens, a friction 
murmur be associated with an endocardial murmur. 



CHAPTER VIII 

THE PHYSICAL DIAGNOSIS OF DISEASES 

OF THE HEART AND OF THORACIC 

ANEURISM 

Enlargement of the heart by hypertrophy and dilatation — 
Valvular lesions, mitral, aortic, tricuspid, and pulmonic — Dis- 
eases of the heart muscle — Endocarditis — Pericarditis— Func- 
tional disorders — Congenital defects — Thoracic aneurism. 

The morbid physical conditions incident to the 
different diseases of the heart, and the signs repre- 
senting these conditions, have been considered in the 
preceding chapter. The diseases are now to be con- 
sidered with reference to the assemblage of signs on 
which the physical diagnosis of each is to be based. 
Most of the diseases of the heart may be diagnosticated 
by means of physical signs. A few cardiac lesions 
do not admit of a physical diagnosis, and they do 
not, therefore, claim consideration in this work. The 
following are the affections which will form separate 
headings in this chapter: Enlargement of the Heart 
by Hypertrophy and by Dilatation, Valvular Lesions, 
Diseases of the Heart Muscle, Endocarditis, Pericar- 
ditis, Functional Disorders, and Congenital Defects. 
Having considered these affections, the physical diag- 
nosis of thoracic aneurism will be the concluding 
topic. 



282 DIAGNOSIS OF DISEASES OF THE HEART 

Enlargement of the Heart by Hypertrophy and by 
Dilatation. — Physical exploration to determine the size 
of the heart has three objects — namely, to determine 
(1) that the size of the heart is normal, or (2) that 
the heart is enlarged, and (3) the degree of enlarge- 
ment. These objects are attainable by means of 
percussion and auscultation, with considerable accu- 
racy, but for truly precise delimitation of the heart the 
orthodiagraph^ method with the x-ray is preferable. 

The heart is of normal size when the apex-beat is 
in its normal situation, that is, in the fifth intercostal 
space/a little within the mid-clavicular line. When the 
superficial cardiac space is not enlarged, as shown by per- 
cussion and by auscultation of the voice (vide page 227) , 
and w T hen percussion show^s the lateral borders of the 
heart to be situated normally — namely, on the left side 
a little within the line of the nipple, and on the right 
side a finger's breadth to the right of the right margin 
of the sternum — these points of evidence warrant 
a positive conclusion that the heart is not enlarged, 
if the lung borders overlapping the heart are normal. 

The fact of an enlargement, and its degree, are de- 
terminable by an abnormal situation of the apex, 
together with an increase of the superficial cardiac 
space, and extension of the lateral boundaries of the 
deep cardiac space, especially on the left side. 

In cases of slight or very moderate enlargement, 
the apex is situated a little without the mid-clavicu- 
lar line, but not below the fifth intercostal space. A 
somewhat greater enlargement lowers the apex to 
the sixth intercostal space, and removes it farther 



DIAGNOSIS OF DISEASES OF THE HEART 283 

without the mid-clavicular line. In greater degrees 
of enlargement the apex is lowered to the seventh, 
eighth, or ninth intercostal space, and generally 
farther removed to the left. The lowering of the 
apex and the removal to the left are not uniformly 
proportionate to each other. As a rule, if the right 
side of the heart be more enlarged than the left, the 
apex is removed without the mid-clavicular line far- 
ther than when the enlargement of the left side of 
the heart predominates, and when the latter is the 
case, the apex is lowered out of proportion to its re- 
moval without that line. The relatively abnormal 
situation downward or to the left, thus, is evidence 
of the enlargement predominating in either the left 
or the right side of the heart. Generally the situation 
of the apex is apparent to the touch, and frequently 
to the eye. In some instances, however, the impulse 
can neither be seen nor felt. How r is its situation to 
be then ascertained? Auscultation furnishes a ready 
and reliable mode of determining this point. The 
situation in which the first sound of the heart has its 
maximum of intensity, as ascertained by means of 
the stethoscope, corresponds to the situation of the 
apex. This is hardly less definite than the presence 
of an appreciable impulse. 

In determining the fact of enlargement and its 
degree by the abnormal situation of the apex, causes 
of the latter w 7 hich are extrinsic to the heart are to 
be eliminated. The apex is removed to the left of 
its normal situation by enlargement of the left lobe 
of the liver, abdominal tumors, hydroperitoneum, 



284 DIAGNOSIS OF DISEASES OF THE HEART 

the pregnant uterus, and gastric tympanites. These 
extrinsic conditions are to be excluded or due allow- 
ance made for them. In some cases in which one 
or more of these extrinsic causes of displacement may 
exist the apex is carried into the axillary region. It is 
to be borne in mind that these causes of displace- 
ment may exist when there is more or less enlargement 
of the heart. All these causes, while they displace 
the apex to the left, do not lower, but tend to raise 
it above its normal situation. On the other hand, 
an aneurismal or other tumor, situated above the 
heart, may press downward the organ, or an unusually 
long first portion of the arch of the aorta may occur, 
and in this way the apex is more or less lowered. 

The superficial space is increased in proportion as the 
heart is enlarged. The extent of this increase is easily 
determined by percussion and auscultation. Within 
this space there is notable dulness on percussion. 
The degree of dulness is greater than within the super- 
ficial cardiac space in health, and this degree of dulness 
is proportionate to the greater area in which the heart 
is uncovered of lung. It is easy to delineate by per- 
cussion on the chest the boundary of the anterior 
border of the upper lobe of the left lung, in other words, 
of the oblique line which is the hypotenuse of the right- 
angled triangle, representing the superficial cardiac 
space in health, and in disease. The area of the super- 
ficial cardiac space is also not less readily and precisely 
ascertained by auscultation of the voice; the limits of 
the lung within the precordia are denoted by an abrupt 
cessation or notable diminution of the vocal resonance. 



DIAGNOSIS OF DISEASES OF THE HEART 285 

In women with large mammae auscultation is more 
available for this object than percussion. The extent 
to w T hich the superficial cardiac space is enlarged, is a 
good criterion of the degree of the enlargement of 
the heart. 

In proportion as the heart is enlarged, the situa- 
tion of the left border is without the mid-clavicular 
line. Its situation is determined by percussion. 
Dulness, although not great, is sufficiently distinct 
within the deep cardiac space, and the line which 
denotes the left border of the heart is easily delineated 
on the chest. This statement holds true with respect 
to the right border of the heart, but this border, even 
when the enlargement of the heart is great, is removed 
comparatively little to the right of its normal situa- 
tion, except in dilatation of the right auricle and right 
ventricle in tricuspid regurgitation, when it is not 
unusual to find the superficial cardiac dulness as much 
as three finger's breadths to the right of the sternum 
in the third and fourth interspaces. By means of 
percussion, the boundaries of the precordia, as enlarged 
by the increased size of the heart, may be determined 
and measured. In making this statement, it is assumed 
that the lungs are not diseased, and that the chest 
is not deformed. Shrinkage of the upper lobe of the 
left lung may enlarge the superficial cardiac space, 
and cause displacement of the heart. The latter is 
an effect of the presence of pleuritic effusion, and it 
may follow its removal. In cases of deformity from 
spinal curvature, to determine the fact of enlargement of 
the heart, or its degree, is not always an easy problem. 



286 DIAGNOSIS OF DISEASES OF THE HEART 

There is a liability to error in localizing the apex 
in some cases of enlargement. Owing to the blunted 
form of the apex, especially when the enlargement 
is chiefly of the right side of the heart, the apex-beat 
may be feeble. It is likely to be overlooked, and a 
stronger impulse in the intercostal space above the 
apex be mistaken for the apex-beat. Of course, the 
lowest impulse is the apex-beat. Careful palpation, 
and finding by auscultation the spot where the first 
sound has its maximum of intensity, will prevent 
this error. 

Enlargement of the heart, and the degree of enlarge- 
ment having been ascertained, it is to be determined 
whether hypertrophy or dilatation predominate. If 
the enlargement be slight or moderate, it may be a 
question whether hypertrophy or dilatation exist 
alone. As a rule, if either of these tw T o forms of enlarge- 
ment exist without the other, it is hypertrophy, for, 
with rare exceptions, hypertrophy precedes dilatation. 
If the enlargement be very great, as a rule, dilatation 
predominates, for the capability of hypertrophic 
increase of size has its limit, and an increase of size 
beyond this limit must be due to dilatation. 

The signs, denoting on the one hand hypertrophy, 
and on the other hand dilatation, relate to the im- 
pulses of the heart and to the heart-sounds. With 
a moderate enlargement, hypertrophy is to be inferred 
from an abnormal force of the apex-beat, and an 
intensification of the systolic sounds, especially the 
sound of impulsion over the apex. With a consider- 
able or great enlargement, if hypertrophy predominate, 



DIAGNOSIS OF DISEASES OF THE HEART 287 

the apex-beat may be abnormally strong and pro- 
longed, but, as already stated, owing to its blunted 
form, the beat is sometimes weak and scarcely appre- 
ciable; the increased power of the ventricular contrac- 
tions, representing the hypertrophy, is then to be 
determined by impulses in the intercostal spaces above 
the apex. These impulses are sometimes present in 
each intercostal space between the apex and the base, 
and they are abnormally strong in proportion as 
hypertrophy predominates. Still more marked evi- 
dence of hypertrophy is sometimes obtained when the 
hand is placed over the precordia; a powerful heaving 
movement is felt. The increased pow r er of the ven- 
tricular contractions may, in some cases, be in this 
way appreciated somewhat as if the heart were held 
in the hand. In cases of considerable or great hyper- 
trophic enlargement, the intensity of the sound of 
impulsion over the apex is notably increased; it is 
prolonged, and its booming quality is more marked 
than in health. Not infrequently it is accompanied 
by a metallic ringing sound or tinnitus. 

Moderate enlargement by dilatation is character- 
ized by abnormal weakness of the apex-beat, and of 
the systolic sounds over the apex. Cases, however, 
of simple dilatation are rare. If the enlargement be 
considerable or great, and dilatation predominate, 
all the impulses are weak, as compared with the cases 
in which hypertrophy predominates, and the sound 
of impulsion over the apex is diminished or nil, the 
feeble, short, mitral valvular sound either supplanting, 
or predominating over the sound of impulsion. These 



288 DIAGNOSIS OF DISEASES OF THE HEART 

points of distinction are marked in proportion as 
dilatation predominates. 

In the great majority of the cases of enlargement 
of the heart, valvular lesions coexist. These coexist- 
ing valvular lesions are represented by endocardial 
murmurs, and they may generally be excluded by the 
absence of the latter. In most of the cases in which 
enlargement exists without valvular lesions, it is asso- 
ciated with either pulmonary emphysema or chronic 
Bright's disease. 



VALVULAR LESIONS 

The physical diagnosis of valvular lesions embraces 
their localization at the different orifices within the 
heart, and the determination of their character as 
giving rise to obstruction and regurgitation, or of 
their innocuousness in these respects. These objects 
of diagnosis involve the endocardial murmurs and 
the abnormal modifications of the heart-sounds which 
were considered in the preceding chapter. Lesions 
at the different orifices — namely, the mitral, aortic, 
tricuspid, and pulmonic — will be considered sepa- 
rately. 

Mitral Lesions. — The lesions at the mitral orifice 
are represented by the mitral murmurs — the mitral 
direct murmur, the mitral regurgitant, the mitral 
systolic non-regurgitant or intra-ventricular, and the 
mitral diastolic murmur. Mitral obstructive lesions 
exist whenever the mitral direct murmur is present, 



VALVULAR LESIONS 289 

with an exception already stated and explained (vide 
p. 263) — namely, this murmur is present in some cases 
in which the mitral valve is intact, aortic lesions, 
giving rise to free regurgitation, existing in these 
cases. These exceptional instances are rare. 

Mitral regurgitant lesions exist whenever a mitral 
murmur which is truly regurgitant is present. A 
systolic murmur having its maximum of intensity at 
or near the apex, transmitted laterally for a certain 
distance beyond the apex on the left side of the chest, 
and heard on the back near the lower angle of the 
scapula, generally, if not invariably, denotes a re- 
gurgitant current; but a systolic murmur limited to 
a small area around the apex, or to the superficial 
cardiac space, is not proof of regurgitation. A truly 
regurgitant murmur, however, may be too feeble to 
be transmitted beyond the apex; the proof of regur- 
gitation must then be based on other evidence asso- 
ciated with the murmur — namely, on enlargement of 
the heart and abnormal modifications of the heart- 
sounds. 

Mitral obstruction may exist without incompetency 

of the mitral valve, as shown by the presence not 

very infrequently of a mitral direct, without a mitral 

regurgitant murmur. The converse of this is of 

more frequent occurrence, that is, regurgitation may 

exist without obstruction. The absence, however, of 

a mitral direct murmur is not positive proof against 

mitral lesions, for, as has been seen, the production 

of a characteristic mitral direct murmur requires 

the obstruction to be caused by an adherence of the 
19 



290 DIAGNOSIS OF DISEASES OF THE HEART 

mitral curtains at their sides, the curtains being suffi- 
ciently flexible to vibrate with the passage of the mitral 
direct current of blood. If these conditions for the 
production of the murmur do not exist, there may be 
no murmur produced by the mitral direct current, 
or, if a murmur be present, it is devoid of the usual 
characteristic quality. Mitral obstruction and regur- 
gitation not infrequently coexist, as shown by the 
presence of both the mitral direct and the mitral 
regurgitant murmur. A mitral murmur, produced 
by a mitral direct current, but diastolic in point of 
time, is sometimes, as has been seen (vide page 265), 
observed in connection with mitral lesions. It is ac- 
cepted now, on accurate experimental and clinical evi- 
dence, that the cause of the change in time of the 
mitral direct murmur, from presystolic to mid-diastolic, 
is the development or onset of fibrillation of the auricle. 
This results in a loss of the presystolic propulsive force, 
which determines the incidence of the usual presystolic 
mitral murmur, as long as the auricle contracts 
effectively. 

The mitral murmurs do not, per se, denote the 
amount of obstruction or regurgitation, or of both 
combined. Information with reference to these points 
may be derived, in the first place, from a comparison 
of the aortic with the pulmonic second sound. The 
amount of obstruction or regurgitation, or both, is 
great in proportion as the aortic sound is weakened, 
or the pulmonary sound accentuated, or both. Per 
contra, there can be but little obstruction or regurgi- 
tation, if the aortic and the pulmonic second sound 



VALVULAR LESIONS 291 

preserve completely or nearly their normal relation to 
each other in respect of intensity. Information may, 
in the second place, be obtained by directing attention 
to the mitral valvular sound (vide page 235). In 
proportion as the function of the mitral valve is com- 
promised by lesions, the mitral valvular sound at the 
apex will be weakened. In some cases this sound is 
lost, the sound of impulsion remaining. 

Enlargement of the right side of the heart, which 
results from mitral obstructive and regurgitant lesions, 
is a criterion of the amount of obstruction and 
regurgitation, taken in connection with the length 
of time they have existed. Hypertrophic enlarge- 
ment of the right ventricle intensifies the pulmonic 
second sound, and allowance must be made for this 
modification in determining, by a comparison of the 
pulmonic and the aortic sound, the degree in which 
the latter is weakened. Attention is to be given to the 
tricuspid valvular sound (vide page 235). The intensity 
of this sound is, in some measure, a criterion of the 
power of the right ventricular systole. 

Aortic Lesions. — Lesions are localized at the aortic 
orifice by the aortic murmurs — namely, the aortic 
direct and the aortic regurgitant murmur. Aortic 
obstructive lesions give rise to an aortic direct mur- 
mur; but it must be considered, in the first place, 
that an aortic direct murmur may be inorganic, and, 
in the second place, that if the murmur be organic 
it may be produced by lesions which occasion no ob- 
struction, and are consequently innocuous. The 
existence of obstructive lesions must be determined 



292 DIAGNOSIS OF DISEASES OF THE HEART 

by evidence added to the presence of the murmur. 
This evidence is either diminished intensity or sup- 
presssion of the aortic second sound, and enlarge- 
ment of the left ventricle. If the lesions which occasion 
obstruction are of a character to diminish or arrest 
the movements of the aortic valve, the aortic second 
sound will be either weakened or lost. If valvular 
lesions be limited to the aortic orifice, the degree of 
enlargement of the left ventricle is a criterion of their 
pathological importance. 

Regurgitant lesions at the aortic orifice give rise 
to an aortic regurgitant murmur. This murmur, of 
course, is always proof of regurgitation; but the mur- 
mur gives no definite information concerning the 
amount of incompetency of the aortic valve. A loud 
murmur may be produced by a regurgitant stream 
so small as to be, for the time, insignificant; and, on 
the other hand, a large regurgitant current may give 
rise to a feeble murmur. The extent to which the valve 
is damaged by the lesions is to be determined, first, 
by either weakness or suppression of the aortic sound, 
and, second, by the degree of enlargement of the left 
ventricle. 

Aortic obstructive and regurgitant, lesions are 
often associated. An aortic direct and an aortic 
regurgitant murmur are then both present, with a 
weakened aortic sound or its suppression, and enlarge- 
ment of the left ventricle according to the amount 
of the obstruction and regurgitation, together with 
the length of time during which the latter have existed. 
These effects, and not the intensity, nor the pitch, 



VALVULAR LESIONS 293 

nor the quality of the murmurs, are indicative of their 
pathological importance. 

Mitral and aortic lesions often coexist, giving rise 
to two, three, or four of the obstructive and regur- 
gitant murmurs in the left side of the heart. In addi- 
tion to the murmurs in these cases, the effects of the 
combined lesions are shown in the modification of 
the heart-sounds, and the enlargement of both sides 
of the heart. 

Tricuspid Lesions. — Tricuspid obstructive lesions are 
exceedingly rare. A few instances of the kind of 
obstruction which is represented by a tricuspid direct 
or presystolic murmur, have been reported. One 
instance has fallen under my observation. In this 
case, as in the other instances which have been reported, 
the tricuspid was associated with mitral lesions; 
hence, in localizing an obstructive lesion at the tricuspid 
orifice, the presence of the presystolic murmur on each 
side of the heart, that is, the coexistence of the mitral 
and the tricuspid direct murmur is to be determined. 
This point has already been considered (vide page 275). 
Signs which are accepted as fairly characteristic of 
tricuspid stenosis are: a presystolic murmur at the 
tricuspid area without accentuation of the second 
pulmonic sound; often in addition an aortic lesion; 
an enlarged right ventricle and auricle, distended 
veins in the neck, frequently without pulsation; 
persistent cyanosis of mucous membranes and skin, 
and marked tendency to edema or general anasarca 
with relatively little dyspnea. The diagnosis should 
be made without a presystolic murmur, as this is 



294 DIAGNOSIS OF DISEASES OF THE HEART 

inconstant. There is almost always coincident mitral 
stenosis. There is likely to be a pulsation recorded 
over the liver coincident with auricular contraction. 

Tricuspid regurgitation is not uncommon. Gen- 
erally the insufficiency is caused by dilatation of the 
right ventricle occurring as an effect of mitral regur- 
gitant or obstructive lesions. Tricuspid regurgitation 
is not always represented by murmur; and when a 
tricuspid regurgitant murmur is present, it is to be 
discriminated from a coexisting mitral regurgitant 
murmur. This point has been considered (vide page 
275). A sign of free tricuspid regurgitation with 
hypertrophy of the right ventricle, is pulsation of the 
liver, which may be seen and felt, and is synchronous 
with ventricular systole. This pulsation is some- 
times notably strong. If the liver be enlarged, the 
pulsation may be communicated to the greater part 
of the abdomen, and its force may be suggestive of 
aneurism of the abdominal aorta. Pulsation of the 
liver may be observed when there is no ventricular jug- 
ular pulse, nor notable turgescence of the cervical veins. 

Pulmonic Lesions. — As compared with aortic lesions, 
these are of infrequent occurrence, and they are 
generally congenital. Lesions giving rise to a pul- 
monic direct murmur may be localized by differen- 
tiating this murmur from the aortic direct murmur 
(vide page 276). It is to be considered that an inor- 
ganic pulmonic direct murmur is not infrequent. 
Pulmonic regurgitant lesions can only be diagnosti- 
cated by determining that a murmur is produced at the 
pulmonic, and not at the aortic orifice (vide page 277). 



DISEASES OF THE HEART MUSCLE 295 



DISEASES OF THE HEART MUSCLE 

None of the diseases of the heart muscle is repre- 
sented by distinctive physical signs, but, nevertheless, 
the physical diagnosis, taking into account the clinical 
history, may be quite positive. The signs, as well as 
the symptoms, are those which denote persistent 
muscular weakness of the heart. The most marked 
evidence is notable weakness of the systolic sounds, 
and especially weakness or suppression of the sound of 
impulsion. In the acute degeneration of the myo- 
cardium which accompanies acute infectious fevers, 
enfeeblement or disappearance of the apex-beat and 
weakness of the systolic sounds are the only signs, and 
the symptoms are only part and parcel of the symp- 
toms of the underlying disease. The same is true of 
the brown atrophy of the heart which occurs in wasting 
diseases, such as tuberculosis and cancer. 

In the more serious changes of acute infectious myo- 
carditis, as seen in diphtheria, acute articular rheu- 
ma ism, some cases of pneumonia and influenza, and 
rarely in other infections, to these signs may be added 
the signs of dilatation of the heart, with or without 
a functional mitral regurgitation. The symptoms of 
muscular weakness of the heart become prominent, 
and various disturbances of rhythm may arise from 
damage to areas of the heart having specialized 
functions. 

Heart muscle weakness is a part of the clinical 
picture of anemia of any severity. Here some dila- 



296 DIAGNOSIS OF DISEASES OF THE HEART 

tation is the rule, the apex-beat is more diffuse, the 
impulse sudden, the sound of impulsion feeble, the 
systolic sound valvular in quality. A systolic murmur 
is heard over the pulmonary artery; also, as a rule, a 
mitral regurgitant murmur, due to dilatation of the 
mitral orifice. In the more severe fatty degeneration 
of the heart of pernicious anemia, similar signs are 
found, but the enlargement is more marked, hyper- 
trophy and dilatation being usual, and the murmurs 
are more pronounced. Venous hum in the neck is 
helpful in the diagnosis of the heart muscle weakness 
of anemia (vide p. 271). 

Chronic myocarditis, as a sequel of acute myocar- 
ditis, of coronary artery disease with multiple small 
infarctions (fibroid myocarditis), or primary, as in 
syphilitic myocarditis, the fatty heart, and other 
chronic affections of the myocardium, cannot be dis- 
tinguished from one another with certainty during life. 
The most that can be attempted wisely is the diagnosis 
of chronic myocardial disease or weakness, and its dis- 
crimination from myocardial weakness secondary to 
chronic valvular disease, adherent pericardium, the 
hypertrophy of B right's disease, emphysema, and so 
forth. The most important physical sign is the loss of 
the sound of impulsion at the apex, the systolic sound 
which is heard being chiefly or exclusively the mitral 
valvular sound. This sound is short and valvular in 
quality, like the diastolic sound. The apex-beat may 
be feeble, or diffuse and shock-like. If the heart be 
dilated, the apparent force of the apex-beat is in 
contrast to the feebleness of the radial pulse. With 



DISEASES OF THE HEART MUSCLE 297 

dilatation, functional mitral, and also tricuspid, regurgi- 
tation may occur, and reach such a grade as to render 
the discrimination from primary mitral valvular dis- 
ease difficult, if not impossible. The history of past 
acute articular rheumatism, or a known mitral mur- 
mur, is of special importance in making the decision. 
In muscular weakness a systolic murmur at the apex 
may be brought out only by exercise. This should 
always be sought for. 

Various disturbances of rhythm may occur, of which 
the most important are heart-block, due to a lesion 
involving the atrio-ventricular bundle, and the per- 
petual irregularity w^hich denotes auricular fibrillation. 
When the latter exists, it may be difficult or impossible 
to distinguish primary myocardial disease from mitral 
obstruction after the disappearance of the mitral direct 
murmur. Here again the history is of more value than 
the physical signs. 

Endocarditis. — The physical diagnosis of endocarditis 
relates especially to its occurrence in connection with 
articular rheumatism. A variety of murmurs may 
occur, the commonest one, and one upon w T hich the 
diagnosis is often based, is a mitral systolic but non- 
regurgitant murmur (vide page 267). The presence 
of this murmur, however, in a case of rheumatism, 
is not positive proof of an existing endocarditis, more 
especially if the patient have previously had articular 
rheumatism, because an endocarditis developed in a 
previous attack may have left a permanent murmur. 
If the murmur be a mitral regurgitant murmur, and 
the heart be enlarged, it is quite certain that endo- 



298 DIAGNOSIS OF DISEASES OF THE HEART 

carditis has previously occurred. The positive proof 
is the production of the murmur during an attack of 
rheumatism, when previous examination, made after 
the commencement of the rheumatic attack, had shown 
that there was no mitral murmur. An aortic direct 
murmur, in cases of rheumatism, is not evidence of 
endocarditis, because in many cases of rheumatism 
this murmur occurs and is to be regarded as inorganic. 

In the variety of endocarditis, known as ulcerative, 
occurring in the course of infectious or septic dis- 
eases, and sometimes without any known point of 
entrance of the infecting organism, an aortic murmur 
may be developed, with or without a coexisting mitral 
murmur, owing to the soft masses present on the valves. 

Acute endocarditis is probably of frequent occurrence 
as secondary to mitral and aortic valvular lesions; 
but, under these circumstances, a physical diagnosis is 
impracticable. 

Pericarditis. — The physical diagnosis of pericarditis 
in the first stage, that is, prior to the effusion of liquid, 
is to be based on a pericardial friction murmur. For- 
tunately for diagnosis, this murmur is uniformly 
present, though at times for only a brief period. Its 
characters as contrasted with endocardial murmurs 
have been stated (vide page 279). The presence 
of a pericardial friction murmur, in connection 
with symptoms denoting pericarditis, renders the 
diagnosis quite positive. There is, however, one 
liability to error. In some cases of pleurisy or pneu- 
monia with pleuritic inflammation, the movements 
of the heart occasion a rubbing together of the 



DISEASES OF THE HEART MUSCLE 299 

roughened pleural surfaces, and in this way a cardiac 
pleural friction murmur is produced (pleuro-pericardial) . 
This may be single or double, and when double, it simu- 
lates the murmur produced within the pericardial sac. 
It is limited to the border of the heart, and is neither 
accompanied nor followed by pericardial effusion. Of 
course, the error of mistaking a cardiac pleural friction 
murmur for one produced within the pericardium, can 
only occur when pleurisy exists, either as a primary 
affection or as secondary to pneumonia, or to pul- 
monary tuberculosis. 

In the second stage of pericarditis, that is, after 
the effusion of liquid has taken place, the pericardial 
friction murmur often, but not always, disappears. 
The physical diagnosis in this stage is then to be 
based on the signs which show T the presence of a greater 
or less quantity of liquid within the pericardial sac. 
The signs which denote pericardial effusion, and its 
amount have been stated (vide page 241). With a 
moderate effusion, the apex of the heart is raised, 
and the apex-beat may be felt in the fourth inter- 
costal space, and removed to the left of its normal 
situation. With considerable or large effusion, the 
apex-beat is lost, and the sounds of the heart are 
feeble and distant. The sound of impulsion is lost, 
leaving the mitral and tricuspid sounds, which are 
short and valvular like the diastolic sounds. 

Increase or diminution of liquid in the second stage 
of pericarditis is readily determined by signs obtained 
by percussion and auscultation. When the quantity 
is much diminished, the friction murmur, if it have 



300 DIAGNOSIS OF DISEASES OF THE HEART 

been suppressed, returns, and persists until the peri- 
cardial surfaces become agglutinated. Xot infre- 
quently, by auscultating when the body of the patient 
is inclined forward, a friction murmur may be heard, 
notwithstanding the pericardial sac contains a large 
quantity of liquid. 

In cases of chronic pericarditis with very large 
effusion, dilatation of the pericardial sac is shown by 
signs obtained by percussion and auscultation. There 
is no apex impulse, the heart-sounds are feeble and 
distant, the systolic sounds being short and valvular, 
and the precordia may be notably projecting. There 
may be systolic retraction at or near the apex- 
beat. 

A malignant morbid growth filling the pericardial 
sac and inclosing within it the heart, may give rise 
to all the signs of pericardial effusion. A case of 
this kind, in a young subject, has fallen under my 
observation. 

With reference to diagnosis, the etiological rela- 
tions of pericarditis should be kept in mind. These 
are acute articular rheumatism, Bright's disease, tuber- 
culosis, and either pleurisy or pneumonia. It rarely 
occurs in other connections, and, as an idiopathic 
affection, it is extremely rare. 

The presence of air and liquid within the pericar- 
dial sac gives rise to loud splashing sounds which, 
occurring when respiration is suspended, and when 
pneumo-hydrothorax is excluded, are at once diag- 
nostic of pneumo-hydropericardium. 



FUNCTIONAL DISORDERS 301 



FUNCTIONAL DISORDERS 

Many of the so-called functional disorders of the 
heart are now recognized as due to distinct localized 
lesions of such parts of the heart and great vessels as 
have to do with the origination and conduction of 
cardiac contractions. For a summary of these the 
reader is referred to the description of irregularities of 
the pulse on page 252. 

There are other groups of symptoms, in which dis- 
order of heart action plays an important role, which 
have no constant or at present recognized structural 
cause, and some are evidently temporary disturbances 
of reflex cardiac nervous mechanism. 

We may consider here angina pectoris, exophthalmic 
goitre, and palpitation. 

By angina pectoris we mean an attack, or recurring 
attacks, of severe substernal pain, which is apt to 
radiate into the arms, and especially to the left arm, 
and is accompanied by a sense of impending death. 
In the majority of cases this is found to be due to 
obliterative diseases of the coronary arteries, and more 
particularly the orifices of these arteries at their 
origins in the aorta, this being often merely a part of 
a general, or extensive aortitis. 

Examination of the heart during or between attacks 
may reveal nothing abnormal. It is upon the history 
and symptoms of the case, and not upon the physical 
findings, that the diagnosis is based. 

Among the causes of rapid heart action is exoph- 



302 DIAGNOSIS OF DISEASES OF THE HEART 

thalmic goitre, in which the most constant of the three 
cardinal symptoms: enlarged thyroid, exophthalmos, 
and tachycardia is the persistently rapid heart action, 
which slows with improvement and increases in rate 
as the patient's condition grows worse. Here, again, 
there is no constant physical finding to account for 
the tachycardia, and at present we must class this 
among the symptoms due to a disorder of nutrition, of 
which the nervous unstability and loss of weight are 
other evidences. 

By palpitation w^e mean a conscious distress in the 
region of the heart or epigastrium, accompanied by 
tumultuous, excessive, rapid, and often vigorous heart 
action. In some people this can be brought about by 
relatively slight reflex irritation, a sudden emotion of 
fear or joy, or indigestion, or it may develop during 
sleep, and without apparent antecedent irritation of 
any kind. The subjective symptoms, the manner of 
development, and the discovery of wholly normal 
conditions on physical examination, serve to make the 
diagnosis. 

Palpitation as a subjective symptom may occur in 
failure of, or failing, compensation, in cases of high 
arterial pressure, and in cases of mitral stenosis par- 
ticularly, among cardiac valvular disorders. It may 
accompany attacks of paroxysmal tachycardia, but its 
association with this condition is not constant, nor is 
subjective cardiac distress at all a constant accom- 
paniment of even severe grades of advanced valvular 
disease with failing compensation. 

In one point of view, the physical diagnosis in 



FUNCTIONAL DISORDERS 303 

functional disorders may be said to rest, not on nega- 
tive, but on positive evidence. Percussion and auscul- 
tation afford the means, not only of excluding inflam- 
matory affections and lesions, but of demonstrating 
the fact that the organ is sound at least as regards 
freedom from ordinary lesions. That its size is normal 
is shown by the normal situation of the apex-beat, 
of the lateral boundaries of the precordia, and of the 
area of the superficial cardiac space. That the valves 
are unaffected is shown by the normal characters 
of the heart-sounds. These positive facts, taken in 
connection with the absence of morbid signs, rendeT 
the diagnosis certain. Positive assurance of the sound- 
ness of the organ should be withheld until painstaking 
examination of the heart, not only by auscultation 
and percussion, but by all the various accessory 
methods, such as the x-ray and electrocardiograph 
has been carried out. Thus will the opinion of the 
examiner carry the weight which is desirable, in order 
to secure for the patient relief from anxiety and appre- 
hension. 

Functional disorders are not infrequently asso- 
ciated with lesions with which they have no essential 
pathological connection. A patient with lesions 
which are either innocuous or attended with little, 
if any, inconvenience, may suffer from disturbance 
of the action of the heart produced by causes which 
are wholly independent of the lesions. There is a 
liability, in these cases, to the error of attributing 
the disorders to the lesions, and thus forming an 
exaggerated estimate of the importance of the latter, 



304 DIAGNOSIS OF DISEASES OF THE HEART 

To decide how much of the disturbed action of the 
heart is due to a superadded functional affection, is 
not as easy as to determine that lesions do not exist. 
The decision must be based on the character, degree, 
or extent of the lesions, as evidenced by the physical 
signs. In this connection may be stated a practical 
maxim which it is well to bear in mind whether func- 
tional disorders exist or not — namely, valvular lesions 
rarely give rise to much inconvenience until they 
have led to enlargement of the heart; and enlarge- 
ment, either with or without valvular lesions, as a 
rule, does not lead to the serious effects which are 
characteristic of cardiac disease, so long as the enlarge- 
ment is due to predominant hypertrophy, and not to 
dilatation. 

CONGENITAL CARDIAC DEFECTS 

There are three kinds of cardiac defects which 
give signs of enough constancy to be susceptible of 
diagnosis during life. They are transposed viscera, 
i. e., a right-sided position of the heart, spleen, and 
stomach with a left position of the liver; defects of 
closure between the systemic and pulmonary circuits, 
i. e., patent interauricular septum (patent foramen 
ovale); patent interventricular septum; patent ductus 
arteriosus, or ductus Botalli; defects in the formation 
of the tricuspid or pulmonary valves resulting in 
stenosis. 

The signs of a right-sided position of the heart on 
inspection, palpation, percussion, and auscultation 



CONGENITAL CARDIAC DEFECTS 305 

differ from the signs obtained in normal individuals 
simply in the change from the left to the right of the 
mid-line. This condition must be sharply distinguished 
from a misplaced position of heart alone, a patho- 
logical state resulting from acquired inflammatory pro- 
cesses within the chest, and, of course, unaccompanied 
by the transposition of the abdominal viscera. 

Patent foramen ovale may give no signs and inter- 
fere in no way with the life of the individual. It may 
cause death. There may be cyanosis and clubbing 
of the fingers. There may be a harsh systolic mur- 
mur, heard best over the second, third or fourth left 
interspaces, and not transmitted along the pulmonary 
artery. The murmur may be diffuse. It may be 
presystolic in time and it may be both diastolic and 
systolic. 

Perforate interventricular septum may be con- 
genital or acquired. The two causes of origin are to 
be distinguished by the history and records of examina- 
tions of the heart at different times. The usual signs 
are: a thrill over the precordium, extending through- 
out systole, and a loud rough systolic murmur heard 
best at the third to fourth left interspaces, near the 
sternum, and widely diffused downward to the left, and 
usually audible in the back. 

Patent ductus arteriosus (ductus Botalli) presents 
fairly constant signs. There is usually a visible sys- 
tolic pulsation in the second left interspace. There is 
a systolic thrill which may even continue through 
diastole. There are the signs of dilatation and hyper- 
trophy of the right ventricle. There is an increase of 
20 



306 DIAGNOSIS OF DISEASES OF THE HEART 

dulness to the left of the sternum, running from third 
to first rib, and across the manubrium of the sternum 
about one and one-eighth to one and one-half inches 
wide, indicating the dilated pulmonary artery. There 
is usually a loud systolic murmur of maximum intensity 
at the second or third left interspace, transmitted up 
to the top of the sternum and left clavicle. There may 
be an increased pulmonary second sound. 

For diagnosis of tricuspid and pulmonary stenosis 
the reader is referred to descriptions of these lesions 
on pp. 293 and 294. 



THORACIC ANEURISM 

The physical conditions incident to thoracic aneu- 
rism which are concerned in the production of signs, 
are: the presence of a tumor within the chest, of vari- 
able size, formed by the aneurismal sac; the passage 
of blood into the sac with each ventricular systole, 
and the expulsion of blood in the diastole by the 
recoil of the coats of the aneurism; the size of the 
opening into the sac as affecting the quantity of 
blood which it receives with each systole; the quan- 
tity of stratified fibrin which the sac contains; the 
point of connection with the aorta of the aneurismal 
tumor, and the direction from this point in which 
the tumor extends, together with its relations to the 
lungs, the trachea, the primary bronchi, the intra- 
thoracic veins, the esophagus, the recurrent laryngeal 
nerve, the sympathetic nerve, either the innominate 



THORACIC ANEURISM 307 

or subclavian artery, the ribs, sternum, and vertebral 
column. 

With reference to diagnosis, it is well to bear in 
mind that, in the great majority of cases, an aortic 
aneurism is connected with either the ascending 
portion, or the junction of the ascending and the 
transverse portion of the arch, and that the tumor 
generally extends to the right in a lateral or antero- 
lateral direction. The physical diagnosis is more 
easily made when the aneurismal tumor is thus con- 
nected. The signs are less available if the aneurism 
arise from the transverse or descending aorta, and 
especially if the tumor extends in a direction down- 
ward or backward. 

An aneurismal tumor which has made its way 
through the walls of the chest, or which, without 
perforation, causes a circumscribed bulging obvious 
to the eye and touch, presents the following diag- 
nostic signs: An impulse is seen and felt which is 
synchronous with the ventricular systole. The force 
of the impulse is variable, depending, aside from the 
force with which the left ventricle contracts, upon the 
size of the orifice between the sac and the artery, and 
the quantity of fibrin which the sac contains. Follow- 
ing the impulse and coincident with the closure of the 
aortic valves, a shock (the diastolic shock) may often 
be perceived if firm pressure be made with the hand. 
A vibration or thrill with each impulse is sometimes a 
marked sign, but is often wanting. Frequently, but 
by no means constantly, a systolic murmur is heard 
over the tumor, and there may be also a diastolic mur- 



308 DIAGNOSIS OF DISEASES OF THE HEART 

mur produced by the passage of blood from the sac. 
Dilatation of the first portion of the arch of the aorta 
usually occurs, of a sufficient degree to establish an 
aortic regurgitation with its characteristic murmur. 
The heart-sounds are transmitted to the tumor with 
more or less increased intensity. There is notable 
dulness on percussion over an area corresponding to 
the space within the chest which the tumor occupies. 
If the tumor be of considerable size, it may produce 
condensation of lung around it; the area of dulness 
on percussion will be in this way extended beyond the 
limits of the tumor. Under these circumstances, 
bronchial respiration and bronchophony may be pro- 
duced. If the aneurismal sac be beneath the integu- 
ment, there may be to the touch a sense of fluctuation. 
With the foregoing signs, the physical diagnosis 
scarcely admits of doubt. Some of the signs may be 
produced by a tumor, not aneurismal, so situated as 
to receive and conduct the aortic impulse. The chances 
of a tumor being so situated as to simulate the signs 
of an aneurism are few. I have met with a case of 
empyema in which perforation of the chest took 
place in the second intercostal space on the right side 
of the sternum, giving rise in this situation to a 
fluctuating tumor which had a strong pulsation. On a 
superficial examination the case seemed clearly one of 
aneurism; but an examination of the chest showed the 
right pleural cavity to be filled with liquid, and a 
puncture in the axillary region gave exit to a large 
quantity of pus, the pulsating tumor disappearing 
after a certain quantity of the purulent liquid had 



THORACIC ANEURISM 309 

escaped. I have met with a similar pulsating tumor, 
incident to empyema, on the posterior aspect of the 
chest. 

When, from its small size or its situation, an aneu- 
rismal tumor does not come into contact with the 
thoracic wall, and when it is situated beneath the 
sternum, signs obtained by palpation and inspection 
being absent, the physical diagnosis is less easy. Im- 
portant signs are: dulness within a circumscribed 
space situated in the course of the aorta; an abnor- 
mal transmission of the heart-sounds within this 
space, and the presence of murmurs. These signs 
are not always available, and when present they are 
not sufficient for a positive diagnosis. Other physi- 
cal evidence, and the prese'nce of certain symptoms, 
render the existence of aneurism highly probable, 
either with or without the foregoing signs. If an 
aneurismal tumor press upon the trachea, it occa- 
sions a tracheal rale, or stridor, together with weak- 
ness of the respiratory murmur on both sides of the 
chest. If the tumor press upon a primary bronchus, 
it occasions diminished or suppressed respiratory mur- 
mur on one side, and increased respiratory murmur 
on the other side of the chest. These physical signs 
should always lead to a suspicion of aneurism in a 
person over forty years of age. Symptoms which 
should excite this suspicion and lead to careful physi- 
cal exploration for the physical signs of aneurism, 
are : dyspnea from spasm or paralysis of the muscles of 
the glottis, and aphonia or impairment of the voice 
without evidence of laryngitis, these symptoms 



310 DIAGNOSIS OF DISEASES OF THE HEART 

denoting either excitation or pressure of the recurrent 
laryngeal nerve; dysphagia from pressure upon the 
esophagus; congestion of the face, neck, and upper 
extremities from obstruction of the vena cava or the 
vena innominata; inequality of the radial, carotid, and 
subclavian pulsation on the two sides, or the absence 
of pulsation on one side, and contraction of one of the 
pupils. These symptoms not only render probable 
the existence of aneurism, but indicate its situation 
as regards the aorta and the direction in which the 
aneurismal tumor extends. 

An aneurism may be suspected, wrongly, when, owing 
to shrinkage of the lung, or deformity of the chest, 
either the aorta or the pulmonary artery just above the 
heart is removed laterally from its normal situation, or 
brought into contact with the walls of the chest in 
the second intercostal space, so as to give rise to an 
appreciable impulse. A murmur may also be present 
at the point of impulse. An error of diagnosis under 
these circumstances is avoided by finding an adequate 
explanation of the signs just noted, and by the absence 
of other signs and of symptoms which are diagnostic 
of aneurism. 

In conclusion, an aortic murmur, however intense 
or rough, is never evidence of aortic aneurism, and, 
on the other hand, the absence of murmur is by no 
means sufficient for the exclusion of aneurism. 



CHAPTER IX 
EXAMINATION OF THE ABDOMEN 

Inspection — Palpation — Percussion — Auscultation — Stomach 
— Liver — Spleen — Kidneys — Abdominal wall — Other organs. 

In making an examination of the abdomen it is 
presupposed that the anatomy and physiology of 
the walls and viscera have been already thoroughly 
mastered. The important points of the change of 
position of the abdominal contents during respiration; 
the change in size and position of the parts of the 
gastro-intestinal tract according to the amount and 
character of their contents; the changes incident to 
filling and emptying of the bladder; the alterations in 
the size and position of the uterus must all be kept 
in mind while examining the abdomen. 

Inspection. — On inspection, we note the occurrence 
of normal or abnormal shadows, betraying the move- 
ments of viscera from the descent of the diaphragm, 
or in the course of peristalsis of their muscular walls. 
Prominences can be detected, especially with the eyes 
on the level of the abdomen, ^nd the patient's feet 
toward the source of light, in the recumbent position. 
Pulsations are noticed. It is normal to see a slight 
epigastric systolic impulse. Peristalsis is not visible 
under normal conditions of the gastro-intestinal tract 



312 EXAMINATION OF THE ABDOMEN 

except in extreme emaciation. Visible peristalsis 
almost invariably indicates obstruction, and the site 
of the obstruction may often be located by close 
attention to the direction, and point of cessation of 
the peristaltic waves. Peristaltic waves may be seen 
in the colon, when there is extreme or acute obstruc- 
tion, which go in the normal and in the reverse direc- 
tion. The lower and upper limits of the stomach, the 
lower border of the spleen and liver, the level of the 
uterus or a distended bladder may be observed on in- 
spection. Tumor masses may be noticed as abnormal, 
fixed or movable prominences as shown by shadows. 
We observe the presence of obesity, the relaxed, 
pendulous, or contracted and sunken parietes. We 
look for edema, meteorism, dilated veins, paying 
particular attention to the system which is enlarged 
and the direction of flow. We notice whether there 
is support by the abdominal walls of their contents, or 
whether there is a general splanchnoptosis or prolapse 
of the viscera with downward and forward displace- 
ment. Inspection should be made in the dorsal, 
lateral, and erect positions. 

Palpation. — Palpation of the abdomen is to be done 
with the patient in the lateral or dorsal positions, the 
abdominal walls being relaxed by posture and comfort 
of the patient. The examining hands should be warm 
and dry. To effect perfect relaxation examination 
may be made in a warm bath, or in extreme need 
under anesthesia. It may be necessary to empty 
the stomach, rectum, and bladder. We note resist- 
ance, fluctuation, the presence of a fluid wave, tumor 



PERCUSSION 313 

masses, sensitiveness to pressure, the movable borders 
of viscera, or the outlines of deeply seated and fixed 
organs. We may note aortic pulsation, the presence 
of mesenteric and retroperitoneal glands, and the 
anterior surface of the vertebrae in thin subjects. 
Errors may arise from reflex muscular tension, fat 
masses in the omentum, or mesentery, or attached 
to the gut, and from fecal masses. 

Percussion. — Percussion of the abdomen is a less 
reliable guide than palpation. The note becomes 
more resonant with increase of gas in the intestine 
or in the free peritoneal cavity, but, with extreme dis- 
tention of the intestine, the note loses its tympanitic 
quality; if there is gas in the free cavity there may be 
shifting dulness from coincident fluid exudate. There 
may be obliterated liver dulness whether the gas be free 
or in the intestine. The note is dulled by a diminution 
of gas in the intestines ; presence of localized solid or fluid 
contents in the intestines; presence of localized inflam- 
matory or neoplastic tissue superficially situated; by 
fluid accumulation in the free cavity, in which case the 
line of dulness or flatness should shift with the patient's 
change of position; and by thick abdominal walls. 

Percussion of the stomach, colon, and small intestines 
is unreliable as compared with inspection and palpa- 
tion; although very light percussion, or auscultatory 
percussion will give fairly accurately the limits of 
stomach and colon if distention with gas or fluid is 
used to exaggerate the notes. 

Percussion of the borders of liver and spleen is merely 
confirmatory of facts better observed on palpation. 



314 EXAMINATION OF THE ABDOMEN 

Percussion of the distended bladder gives marked 
dulness if a light stroke is used. 

Percussion over the enlarged uterus gives a similar 
change of note, but palpation, catheterization, and 
vaginal examination serve to prevent confusion in 
this instance. 

Percussion of the kidneys is unprofitable. 

Auscultation. — Auscultation, except as combined 
with percussion, gives no positive results of value 
except in identifying the occurrence and location of 
the fetal heart-sounds, the uterine, placental, and 
cord murmurs in pregnancy, and murmurs due to the 
pressure of tumors on the abdominal aorta, or over 
abdominal aneurisms. 



STOMACH 

Examination of the stomach should include a deter- 
mination by palpation and inspection of its size, 
location, character of its contractions, and its outlines 
when empty and when distended. Visible peristaltic 
waves seen passing from the left hypochondrium across 
the abdomen to end at the right of the umbilicus in a 
temporary prominence are diagnostic of pyloric stenosis. 
Points or areas of acute tenderness may be made out 
over its surface. Tumors of its walls or of the pylorus 
may be detected. By dipping, or quickly striking the 
wall, over the stomach we may elicit splashing when 
the stomach contains food, thus indicating its ability 
to empty itself ,|or its motility and the patency of the 



LIVER 315 

pylorus. In spite of the apparent accuracy of some of 
these methods combined with the use of the stomach 
tube, there is no question that reliable #-ray examina- 
tions will give us more exact data as to size, location, 
and function than all the other methods combined, and 
this is equally true with regard to the other parts of 
the intestinal tract. 



LIVER 

The liver may be palpable in health owing to unusual 
shape of the costal margin or angle, or when displace- 
ment downward has resulted from faulty position or 
dress. The border may be palpable under these condi- 
tions even though its consistency is not unduly resistant. 
The liver may be displaced downward, or upward, ac- 
cording to the relation between the intrathoracic and 
intra-abdominal pressures, particularly in relation to 
the right side of the diaphragm in hydro- or pneumo- 
thorax, or in hydro-pericardium, and in meteorism, 
ascites, and pregnancy. The gall-bladder may be pal- 
pable and detected on percussion, to the right of mid- 
clavicular line at the costal margin, if it is distended by 
any of the obstructive affections which may interfere 
with the patency of the cystic duct. Detection of 
tenderness in the region of the gall-bladder, or just 
below it, may be an important point in distinguishing 
affections of the gall-bladder from more or less general 
abdominal pain, or appendical or gastric pains. 

We find a slight enlargement of the liver in acute 
catarrhal jaundice. 



316 EXAMINATION OF THE ABDOMEN 

In liver abscess the liver may be painful and irregu- 
larly increased in size. 

In interstitial hepatitis (cirrhosis) there is usually 
uniform enlargement. The surface is firm and resistant, 
the edge hard, and unevenness may be detected. The 
spleen is usually enlarged as well. There is apt to be 
icterus and no ascites. 

In carcinoma of the liver there is unequal enlarge- 
ment, and a lumpy surface; there is usually icterus and 
ascites, but the spleen is not enlarged. 

In echinococcus cyst of the liver there is usually a 
fluctuating tumor. Icterus is often present. The 
spleen is not enlarged, and ascites is not present. 

In chronic passive congestion of the liver we find 
an enlarged, firm, sometimes tender liver. Icterus 
may occur but does not persist. The spleen is not 
enlarged, and ascites is not present, unless there is 
edema of dependent parts of the body or hydrothorax 
as well. 

The liver may be enlarged in syphilis, when we 
find it hard and lumpy. The spleen large; ascites 
and icterus present or absent. 

The amyloid liver is evenly enlarged, and smooth, and 
firm. The spleen is enlarged. Xo icterus or ascites. 

In leukemia the liver is enlarged but to a less degree 
than the spleen. No icterus or ascites. 

The liver is decreased in size in atrophic forms of 
chronic hepatitis, and in acute yellow atrophy of the 
liver. In the former we find an enlarged spleen, much 
ascites, slight icterus. In the latter we have extreme 
icterus, without enlargement of the spleen, or ascites. 






SPLEEN 317 



SPLEEN 



The outlines of the spleen can be determined by 
percussion, except for its posterior pole {vide p. 62). 

By palpation, the lower pole of the spleen is to be 
felt if the spleen is enlarged. Palpation should always 
be carried out in two ways unless the spleen is easily 
felt. With the patient in the dorsal position, the 
examiner faces the patient, standing on his right side, 
and palpates gently in the left hypochondrium, the 
fingers of one hand pressing gently upon those of the 
other until the hand upon the abdominal wall is at or 
just beneath the costal margin at the anterior axillary 
line. The patient is directed to breathe in deeply, and 
as the diaphragm descends the soft tip of the spleen 
will be felt, with moderate enlargement. If this pro- 
cedure fails, the examiner should stand at the patient's 
back while the patient lies upon his right side. The 
examiner, facing toward the patient's feet, hooks the 
fingers of his right hand over the costal margin, to feel 
the spleen as it is forced down in inspiration. When 
the spleen is markedly enlarged it may be missed if 
the examiner's hand is applied too near the ribs or too 
far posteriorly in the flank. Tenderness and uneven- 
ness of the margin may be observed. 

If the splenic flexure of the colon is full of feces, the 
splenic dulness cannot be made out. If the stomach 
contains food, percussion over the spleen must be 
made with the patient on his right side. 



318 EXAMINATION OF THE ABDOMEN 

Emphysema, meteorism, or ascites may cause a 
loss of splenic dulness. If the spleen is palpable, or 
the dulness reaches the anterior axillary line the spleen 
is enlarged. Enlargement occurs in many infectious 
diseases, especially in typhoid fever, and in malaria, 
typhus fever, and sepsis. The spleen is enlarged in 
cirrhosis of the liver, infarct of the spleen, amyloid 
disease, and the true and pseudo-leukemias. The 
spleen may be enormously enlarged without apparent 
cause, in tropical diseases splenic anemia, polycythemia, 
splenomegaly, and Banti's disease associated with types 
of grave anemia. 

KIDNEYS 

The kidneys cannot be percussed with profit. 
Changes of size and position can usually be determined 
by palpation. Palpation is used with the patient 
lying on his back, side, or abdomen, or in a semi-erect 
seated posture. An effective way of detecting a mov- 
able kidney is to grasp the abdominal wall gently with 
one hand, the palmar surface of the fingers against the 
lumbar muscles and the thumb pressing backward. 
The lower pole of the kidney if it descends on inspira- 
tion forces the thumb and fingers apart. By using 
bimanual palpation with one hand behind, just below^ 
the eleventh rib, and the other pressing back against 
the abdominal wall, the posterior hand appreciates 
increased resistance, as an enlarged kidney is forced 
down in inspiration. When freely dislocated even the 
upper pole may be palpated. Enlarged kidneys are not 



ABDOMINAL WALL 319 

so easily felt, nor do they so often move with the dia- 
phragm, as do prolapsed kidneys. The colon is usually 
pressed forward by an enlarged kidney, the relative 
positions of colon and kidney being readily ascertained 
after artificial distention of the colon with gas. 



ABDOMINAL WALL 

Abdominal distention occurs in meteorism, which 
is a common incident in entero-colitis, typhoid fever, 
in peritonitis, and in obstruction of the gut. In 
peritonitis there is extreme tenderness either general- 
ized, or, if the process is localized as an appendical 
abscess, inflamed gall-bladder or ruptured gastric or 
intestinal ulceration, the tenderness may be sharply 
circumscribed, with muscular spasm extending more 
or less widely. At a point half-way between the ante- 
rior superior spine of the ilium and the umbilicus, the 
tenderness of appendical inflammation is usually sharply 
localized (McBurney's point), and, if the colon is dis- 
tended with air, this point may be the seat of acute 
pain in chronic inflammations of the same region. 

In perforation of the wall of the stomach or intestine, 
there is apt to be a marked increase in the intensity 
of abdominal tympany, and liver and splenic dulness 
may disappear. With this, there is rapid weak pulse, 
and signs of a general peritonitis. 

In obstruction of the gut, the signs may develop 
acutely or slowly according to the nature of the cause, 
whether kinking, intersusception or embolus on the 



320 EXAMINATION OF THE ABDOMEN 

one hand, or progressive tumor growth, etc., on the 
other hand. The small, weak, rapid pulse, and absence 
of passage of flatus and feces, together with violent 
peristalsis, distention, and vomiting make the picture 
striking. The rectum and usual sites of hernise should 
be examined. 

The abdomen may be distended from ascites, in 
cardiac, renal, or hepatic disease, or in such peritoneal in- 
flammations as occur in peritoneal carcinosis, and tuber- 
culosis. In the latter two conditions there is often 
little or no tenderness of the abdomen, and in each 
condition the exudate may be localized, or capsulated, 
as it were, in some one portion of the peritoneal sac. 

OTHER ORGANS 

The rectum should always be examined digitally, 
and if necessary instrumentally. The bladder and 
vagina should be explored if there is any indication of 
interference with their function or structure, and often 
for the sake of determining the position of adjacent 
inflammatory or neoplastic processes. The stomach 
should usually be explored, information at the same 
time being obtained as to the patency and size of the 
esophagus. 



CHAPTER X 
EXAMINATION OF THE NERVOUS SYSTEM 

General signs — Localizing signs — General examination of the 
nervous system — Motility — Sensibility — Reflexes — Trophic dis- 
turbances — Vasomotor disturbances — Electrical irritability — 
Special examination of nervous system — Examination of cranial 
nerves — Pathological gaits and postures. 

GENERAL AND LOCAL MANIFESTATIONS OF 
BRAIN DISEASE 

Certain general symptoms may and usually do appear 
in the course of any cerebral affection, due to irritation, 
or cessation of its functions as a whole. A few phe- 
nomena occur which are of value, as convulsions, 
optic neuritis with characteristic ophthalmoscopic 
findings, variations from normal in pulse, and respira- 
tion rates, and in body temperature, disturbances 
in the secretion of sweat, vasomotor and nutritional 
disturbances. 

Localizing symptoms occur also, and upon them 
we depend for determining what particular part of 
the brain is diseased, e. g., spasm or paralysis of one 
or more extremities, or half the body, loss of sense 
of touch, pain, temperature or position of the extremi- 
ties, or half the body, loss of sight, smell, taste or 
hearing, disturbances of speech. Unless the motor or 
21 



322 EXAMINATION OF THE NERVOUS SYSTEM 

sensory areas of the brain are involved, all of these 
localizing signs may be lacking. 

These general and localizing signs depend, not upon 
the character of the lesion, but upon its location and 
ability to produce destructive pressure. 

General Signs. — Convulsions vary as to location, 
extent, duration, and sequence of the extension. They 
may be clonic or tonic, or combined. They may be 
preceded by a cry, the result of laryngeal or respira- 
tory spasm, and there may be injury of the tongue, 
frothing at the mouth, and evacuation of the stomach, 
rectum, and bladder. 

Optic neuritis is of slow development, not neces- 
sarily accompained by blindness, but there is a dimness 
of vision early, and loss of sight in advanced stages- 
By the ophthalmoscope, characteristic changes are 
seen in the optic disc, and retinal vessels. 

Venous congestion, limited of degree or unilateral, 
with vascular relaxation, increased sweating and local 
edema, may be seen. 

Emaciation may be severe, in spite of a sufficiency 
of food ingested, and ability to digest it. 

Localizing Signs. — By noting the set of muscles first 
or chiefly involved in a spasm, the location of a cortical 
lesion may be determined with some accuracy. 

Limited convulsive movements, or cortical spasms 
(Jacksonian epilepsy) may occur, followed by weak- 
ness or paralysis of the muscles involved in the attack, 
the subsidence of the paralysis occurring in an order, 
the reverse of the order of involvement at the time 
of the attack. 



MANIFESTATIONS OF BRAIN DISEASE 323 

Paralysis of voluntary motion of one muscle, or many, 
may be present, while reflex acts involving the same 
muscles may occur, indicating a cortical as distinct 
from a subcortical or spinal paralysis. 

Fig. 13 




The functional areas of the cerebral cortex. Left hemisphere. (Starr.) 



Aphasia of a motor or sensory type may exist, due 
to interference with complex cortical motor centres. 
Dysarthria or anarthria may occur from interference 
with the cortical centres for the facial muscles. 

Monoplegia, hemiplegia, paraplegia, and crossed or 
alternating paralyses may occur, according as the 
lesion is small or large, or is at the cortex, or in 
the course of the motor tracts between the cortex, the 
base of the brain, the medulla and cord. 



324 EXAMINATION OF THE NERVOUS SYSTEM 

Disturbance of sensation may occur alone or with 
motor paralysis, the site of lesions to be determined 
by the same laws as are followed in analyzing motor 
paralysis. 

Hemianesthesia, hemianalgesia, hemithermo-anes- 
thesia, and hemiataxia may follow a cortical lesion of 
large extent or result from smaller lesions in the sub- 
cortical course of the sensory tracts in the internal 
capsule, crura, and medulla, the approximate loca- 
tion of the lesion to be determined by a knowledge of 
the anatomy of the ascending paths from cord, and 
medulla, to cortex. 

Disturbance of Vision. — Since each optic nerve is 
supplied with fibres from each optic tract, any cerebral 
cause of blindness gives hemianopsia, as in occipital 
lobe lesions. The blindness may be for color vision, 
for one or two colors, or be total. Symmetrical blind- 
ness in both eyes is of cortical origin. Incomplete 
hemianopsia, w T ith some blindness of the remaining 
fields, may occur in subcortical, or basal ganglia 
lesions in the vicinity of the terminations of the 
optic tracts. 

Disturbance of hearing may prove to be a local- 
izing sign, when the lesion is in both temporal lobes, 
or in the tracts leading from the ears to them. 

Disturbance of the sense of smell is rare, and, if it 
occur, its significance is unknown. 

Disturbance of sense of position giving a peculiar 
ataxic, staggering gait, but not in evidence unless 
standing or walking, may indicate a lesion in the 
vermes of the cerebellum. 



EXAMINATION OF THE NERVOUS SYSTEM 325 

Although no examination is complete without an 
estimate of the psychical condition of the patient, 
such tests form no proper part of the physical signs, 
present in diseases of the nervous system. There are, 
however, four distinct psychical states, occurring 
so frequently in general clinical experience as to be 
properly named here, viz., depressed and irritative 
disturbances of consciousness; disturbances of intelligence, 
and of memory. 

The examination of the nervous system falls under 
the headings, general and special, as follows: 
General: 1. Tests of motility. 

2. Tests of sensibility. 

3. Tests of reflexes. 

4. Examination of trophic disturbances. 

5. Examination of vaso-motor disturbances. 

6. Tests of mechanical irritability of muscles and 
nerves. 

7. Tests of electrical irritability of muscles and 
nerves. 

Special: 1. Examination of the cranial nerves. 
2. Pathologic gaits and postures. 



GENERAL EXAMINATION OF NERVOUS SYSTEM 

Motility. — Voluntary motions, with or without meas- 
ured resistance, are undertaken by the patient at the 
examiner's order, giving evidence of more or less 
paralysis, paresis, or motor weakness, and confirming 



326 EXAMINATION OF THE NERVOUS SYSTEM 

evidence on inspection, of atrophy, or diminished size 
of the muscles tested. By testing symmetrical groups 
at the same time, even slight irregularities of power 
appear. 

Motor irritation appears as involuntary muscular 
acts; clonic spasms repeated in series or shocks and 
chiefly incoordinated; tonic spasms, long continued 
rigid convulsions, as in tetany, tetanus, strychnine 
poisoning, meningitis; contractures, active or passive, 
the former a prolonged tonic spasm, disappearing under 
narcosis, the latter due to a shortening of the muscle; 
fascicular (or fibrillary) twitching, occurring in paretic, 
or paralyzed muscles, and similar to the action of 
healthy muscles exposed to cold; tremor, rapid, slight, 
rhythmic contractions, either occurring with increas- 
ing vigor with purposeful movements, the intention 
tremor, or occurring during inactivity. The intention 
tremor is peculiar to multiple sclerosis, and is essen- 
tially a clonic muscle reflex. The tremors of rest vary 
in their rate, location, and quality. Paralysis agitans 
tremor is slow (5 to 6 a second), first in the hands, 
coarse and largely inhibited by voluntary impulse. 
Senility gives a slow (4 to 6 a second) tremor first 
in the head, and intention may bring it out in mild 
cases, while in severe grades it persists during inac- 
tivity. In neuroses, and exophthalmic goitre we have 
a fine rapid (8 to 9 a second) tremor in the ex- 
tended fingers. Toxic tremors are rapid, the type in 
alcoholism appearing first in the hands and lips. Vigor- 
ous muscular exertion, mental excitement and intense 
cold may give confusing tremors in health. Choreic 



TEST OF MOTILITY 327 

movements, aimless and involuntary, may involve 
the entire body, and prevent locomotion, and volun- 
tary acts. Hemichoreic motions may occur in lesions 
of the posterior part of the internal capsule, or of the 
optic thalamus. If the movements are slow and regu- 
lar, though aimless and involuntary, we call them 
athetoid, and these are seen in long-standing hemi- 
plegias, and in Friedreich's ataxia. 

Cataleptic rigidity, or a fixing of the limbs with a 
waxy, passive resistance, the position not being resumed 
when forcibly altered, occurs in hysteria, hypnosis, 
the psychosis katatonia, and rarely in the stupor 
accompanying brain tumor. Myotonia is an undue 
muscle tension occurring momentarily, and hindering 
the first of a series of voluntary motions, and is seen 
only in myotonia congenita or Thomsen's disease. 

Ataxia or incoordination of muscular movements 
causes excessive or unexpected results of voluntary 
effort. 

The patient is tested in the performance of coarse 
and then fine movements of the body and extremities, 
as standing, walking, touching nose with index finger, 
etc., the value of the tests being increased by shutting 
the eyes to cut off the aid of vision in directing the 
voluntary movements. Romberg's symptom consists 
in more or less noticeable swaying, in patients who 
stand with feet close together, and eyes closed, and in 
severe cases, even with the eyes open. It is evidence 
of disturbance of equilibrium, from anesthesia, or 
ataxia without anesthesia, in the lower extremities, 
and in affections of the cerebellum. Ataxia is a 



328 EXAMINATION OF THE NERVOUS SYSTEM 

typical finding in tabes dorsalis, and in Friedreich's 
ataxia, in motor cortical lesions, in polyneuritis 
(especially alcoholic) and occasionally in multiple 
sclerosis. 

Interference with any member of the reflex or 
coordination arc may produce ataxia, whether the 
error be in the sensory limb, the psychomotor centre, 
the adjacent point of transfer to the centre from the 
centripetal limb, or in the motor limb. 

Cerebellar ataxia, a result of cerebellar disease of 
the vermes alone, gives a peculiar reeling gait, while 
the arm and leg movements appear normal when the 
patient is in bed. A similar gait is seen where there 
is a loss of the usual stimulation of the cerebellum 
from the semicircular canals, or even from the audi- 
tory tract or from the eye muscles. 

Sensibility. — Sensibility may be tested by delicate 
or firm pressure with cotton, hairs, the finger or metal 
weights or springs, and should be done with the 
patient's eyes shut. There may be increase, decrease, 
or absence of sensation of touch or pressure, i. e., 
hyperesthesia, hypesthesia, or anesthesia. If a soft 
touch elicits pain or the stick of a pin fails to, we 
observe hyperalgesia or analgesia in particular areas. 
By using test-tubes with cold and warm water we can 
determine areas of altered or lost thermal sensibility. 
Particular areas of increased sensitiveness to pain, 
or so-called hyperalgesic zones, are recognized as 
constantly associated with diseases of deeper organs. 
The location of these various zones has been established 
by Head and Quincke [vide pp. 330 to 332). 



REFLEXES 329 

Reflexes. — When testing reflexes it is necessary to 
avoid the inhibiting influence of the patient's atten- 
tion to the particular act to be tested, and to be sure 
that the muscles involved in the act are fully relaxed 
before the reflex is elicited. The simplest device is 
to have the patient shut his eyes and pay attention 
to some question put to him by the examiner. Repeti- 
tion may be necessary, but loss of reflex from fatigue 
may cause a faulty diagnosis of absence of reflex. 
The cutaneous reflexes to be tested are; plantar: plantar 
flexion of toes on tickling the sole of the foot; cremas- 
teric: drawing up of the testicle when the skin on the 
inner surface of the thigh on the same side is lightly 
stroked; inguinal: contraction of the lower fibres of 
the internal oblique muscle on stroking the inner sur- 
face of the thigh; abdominal: contraction of transverse, 
oblique, and rectus muscles at the levels at which the 
of the abdomen is quickly stroked. 

Tendon reflexes to be tested are the knee-jerk, or 
patellar reflex: contraction of the quadriceps extensor, 
when the patellar tendon is sharply struck as by the 
edge of the hand. Ankle clonus or Achilles-tendon 
reflex: single or persistently repeated plantar flexions 
of the foot, on making the Achilles tendon tense by 
passive dorsal flexion of the foot. 

Other reflexes are frequent, on stretching individual 
muscle tendons or striking bony prominences or 
joints if there is a general increase in reflex irritability, 
but they are too inconstant in health to be important 
in disease. 



Fig. 14 




For description see Fig. 15. 



Fig. 15 




Hyperalgesic and radiation 
zones of the skin in diseases of 
deeply situated organs. Zones 
on the trunk and extremities: 
Diseases of the heart, pain and 
hyperesthesia in zones, C3 (see 
Fig. 16), D\, D4', tuberculosis of 
the lungs, D1-D7, particularly 
Z>2, -D4, D$; diseases of the 
esophagus, particularly D&, D$, 
Ds; diseases of the breast, D4, D5; 
diseases of the stomach, D7, Ds, 
D$; diseases of intestine (pylorus, 
colon), Z>io, -D11, D12; diseases of 
liver, Z>7, D&, Dq, Dio; diseases 
of the kidney and ureters, D10, 
Dn, L\\ diseases of the bladder, 
S2, S3, S4; diseases of the ovaries 
and testicles, D10; diseases of 
the uterus, D±o, Du, Dn, L\\ 
diseases of the cervix, Si, S2, S3, 
S 4 . (After H. Head.) 



332 EXAMINATION OF THE NERVOUS SYSTEM 

The presence of normal reflexes is important, less 
reliable information being elicited when they are 
absent or increased. 



Figs. 16 and 17 



Nasofrontal zone 

Maxillary zone 
Nasolabial zone 



Middle orbital zone 

Temporofrontal zone 
Temporal zone 




laryngeal zone 



Middle orbital zone 



Temporofrontal zone 
Temporal zone 




Sincipital zone 
Parietal zone 



Occipital zone 
Mandibular zone 

Hyoid zone 



Upper | 
Lower ) 



Laryngeal zone 






TROPHIC DISTURBANCES 333 

The Babinski phenomenon consists in a reversal 
of the normal plantar reflex, in that, when the sole of 
the foot is scratched, there is a dorsal flexion of the 
great toe, and usually a plantar flexion of the other 
toes. This is a pathological plantar reflex, and depends 
nearly always upon a lesion of the pyramidal tract. 

Trophic Disturbances. — Trophic disturbances include 
affections of muscle, skin, bones, and joints. Muscles 
may be increased in bulk with increased strength 
physiologically, and pathologically in Thomsen's dis- 
ease, and in congential hypertrophy. They may be 
increased in bulk, with decreased or stationary strength, 
where the increase is due to fat and connective tissue, 
i. e., a pseudo-hypertrophy with a true progressive 
muscular dystrophy. Atrophy may result from disuse 
and be accompained by degeneration. If degenera- 
tion, i. e., a pathologic proliferation of connective 
tissue occurs, we have a progressive muscular atrophy 



Description of Figs. 16 and 17. 

Hyperalgesic and radiation zones of the skin in diseases of deeply situated 
organs. Zones on the head and neck: Nasofrontal zone, diseases of the eyes, 
nose, and upper incisors; middle orbital zone, in hypermetropia ; temporo- 
frontal zone, diseases of the ears and heart, temporal zone, in glaucoma. 
(After H. Head.) 
Sincipital zone: Diseases of the middle Nasolabial zone: Diseases of the nose 

ear. and dental pulp. 

Parietal zone: Diseases of the ear and Mental zone: Diseases of the incisor 

stomach. and canines. 

Occipital zone: Diseases of the pos- Hyoid zone: Diseases of the tonsils, 

terior half of the larynx and certain tongue, and lower molars. 

abdominal viscera. 
Maxillary zone: Diseases of the iris Upper laryngeal zone: Diseases of 

and vitreous body. the dorsal surface of the tongue and 

the wisdom teeth. 
Mandibular zone: Diseases of the Lower laryngeal zone: Diseases of 

upper molars. the larynx. 



334 EXAMINATION OF THE NERVOUS SYSTEM 

as a result of primary disease of the muscle, or 
secondary to interference in its nutritive control, by 
degeneration or inflammation of the nerve path, or 
of the ganglion cells in the spinal centres, and in the 
nuclei of the lower cranial nerves. 

The muscular power may be diminished in propor- 
tion to the atrophy, or the power may be lost first, 
followed later by atrophy. 

Trophic disturbances in the skin, occurring in a 
variety of severe diseases particularly in transverse 
lesions of the spinal cord, result in necrosis, as the bed- 
sore or decubitus. Its distribution may be unilateral, 
as in severe cerebral hemiplegias. There may be 
areas of atrophy of the skin, causing a glazing, pig- 
mentation, ulceration or gangrene. 

Trophic disturbances of bones or joints may occur 
with interference of bone growth, or overgrowth of 
bone and cartilage at joints, as is seen in tabetic 
arthropathy, or Charcot joints. Hypertrophy of the 
bones of hands, feet, nose, and lower jaw sometimes 
associated with disturbed function of the hypophysis 
cerebri is known as acromegaly. 

Vasomotor Disturbances. — Disturbances of sweat- 
secretion, increase or decrease, is of frequent occurrence, 
but of little diagnostic value. An exception is in the 
case of increased perspiration in acute polyneuritis, 
affecting the extremities, which occurs with enough 
constancy to be useful in diagnosis. 

Electrical Irritability. — Electrical irritability of muscle 
and nerve is tested, by using unipolar stimulation of 
the muscle direct, or by application of the stimulating 



EXAMINATION OF THE CRANIAL NERVES 335 

electrode to certain accessible points over the nerve 
supplying a muscle. The strength of current, whether 
induced or direct, needed to elicit contraction, or the 
differences in the strength of contraction at sym- 
metrical points on two sides of the body, with currents 
of equal strength, are used to determine variations in 
irritability of muscle and nerve. 

Where there is a degeneration of muscle or nerve 
certain characteristic changes in electrical irritability 
are found, viz.: (1) Diminution or loss of Faradic 
irritability, or a decidedly weaker reaction than to 
galvanism; (2) a delayed and prolonged reaction 
instead of a sudden twitch; (3) a partial or complete 
reversal of the law of unipolar stimulation whereby the 
anodal closing contraction is greater than the cathodal 
closing contraction, instead of the reverse as is the case 
in health. Marked hyperirritability to galvanism is 
present before other signs develop in tetany. 



SPECIAL EXAMINATION OF NERVOUS SYSTEM 

Examination of the Cranial Nerves. — Olfactory 
Nerve. — Olfactory function is readily tested, but gives 
no reliable data, unless the condition of the mucous 
membrane of the nose is undoubtedly normal. 

Optic Nerve. — The optic nerve function can be 
accurately tested by examining acuteness of vision 
after correction of errors of refraction, by plotting the 
field of vision w T ith a perimeter for general and color 
fields. 



336 EXAMINATION OF THE NERVOUS SYSTEM 

In examining the function of the third, fourth, and 
sixth nerves it is well to bear in mind the muscles 
supplied by each, and then to consider the signs as 
observed upon the joint action of all three nerves 
rather than upon any one alone. The third cranial 
(oculomotor) nerve supplies the levator palpebrse 
superioris, rectus superior, rectus inferior, rectus inter- 
nus, and obliquus inferior, the pupillary sphincter and 
the muscles of accommodation. The fourth cranial 
(trochlear) nerve supplies the superior oblique. The 
sixth cranial (abducens) nerve supplies the external 
rectus muscle. 

1. We test the mobility of the eye in various direc- 
tions, both with its mate and alone, while the head 
is kept fixed. Convergence upon a near point serves 
to test the internal recti. Rotation is tested by having 
the eyes follow the finger upward and outward, and 
then downward and outward. While looking upward 
and outward, rotation of the right eye in the direction 
of the hands of the clock, signifies paresis of the 
inferior oblique, and preservation of the superior rectus; 
while looking downward and outward, a similar rota- 
tion signifies paresis of the inferior rectus with intact 
superior oblique. Extreme paralysis of the eye muscles 
may result in strabismus. 

Ocular muscle paralysis is due in almost every in- 
stance to lesions of the peripheral motor neurons; 
the nuclei of the ocular muscles being innervated by 
both hemispheres. A unilateral hemisphere lesion is 
ineffective, and bilateral ones extremely rare. When 
the lesion is purely peripheral the nerve is affected as 



THIRD, FOURTH, SIXTH CRANIAL NERVES 337 

a whole, while if the lesion is nuclear, in the majority 
of cases the pupillary and accommodation fibres of 
the oculo-motor are not involved, since the oculo- 
motor nucleus is distributed in different areas, the 
separate parts having, however, identical functions. 

2. Ptosis, or a paralytic drooping of the upper eye- 
lid, usually results from paralysis of the levator 
palpebrae superioris, supplied by a branch of the 
oculo-motor. 

3. Conjugate paralysis, or deviation of the eyes, 
consists of weak or absent mobility of the two eyes to 
the same side, the patient looking toward his cerebral 
lesion, if the lesion is above the pons, and away from 
it, if the lesion is in the pons. It is a common symp- 
tom in such cerebral lesions as hemiplegia, resulting 
from hemorrhage or softening. 

4. Nystagmus is a rhythmic oscillation of the eye- 
ball, generally an intention tremor, but often occurring 
in extreme positions of the eye-ball, in many affections 
of the €ye, of the brain, and of the labyrinth. 

5. Grafe's sign consists in a delay of the upper lid 
in following the eye-ball, as the eye is turned slowly 
downward, to follow the examiner's finger, thus 
showing a broad band of sclera above the cornea and 
giving a characteristic appearance to the patient in 
exophthalmic goitre. 

6. Pupillary Phenomena. — A. A narrow pupil may 

result from exposure to bright light, during sleep, 

in old age, and during accommodation for near vision 

physiologically. A narrow pupil occurs pathologically, 

early in tabes dorsalis, and in progressive paralysis, 
22 



338 EXAMINATION OF THE NERVOUS SYSTEM 

from the action of various drugs, eserine, pilocarpin, 
opium, advanced choloroform narcosis; from lesions 
of the pupillary dilating fibres of the cervical sympa- 
thetic, or lesions of the sympathetic itself, or of the 
oculo-pupillary fibres connecting the sympathetic nerve 
with the first dorsal segment of the spinal cord. 

B. Dilated pupil occurs in loss of consciousness, in 
severe pain, in dyspnea, in peripheral blindness (optic 
atrophy and glaucoma), in general oculo-motor par- 
alysis, rarely in tabes dorsalis, and progressive paralysis, 
and from atropin, duboisin, cocain, and early choloro- 
form narcosis, and from the local application of 
epinephrin. 

C. Inequality of the pupils may occur as result of 
unequal refraction of the two eyes in health. It is 
common in unilateral cerebral affections, tabes dor- 
salis, progressive paralysis, and in unilateral disease 
of sympathetic, oculo-motor, or optic nerves, and in 
migraine attacks. 

D. Anomalies of pupillary contraction may occur, 
such as sluggishness or absence of the pupillary 
light reflex. The pupil may fail to contract to light, 
in bilateral cerebral pressure, in focal lesions which 
interrupt the reflex arc, in complete peripheral oculo- 
motor paralysis, as a result of drugs mentioned as 
dilating the pupils, in affections of the retina, and 
in bilateral optic atrophy, or marked choked disk. 
The pupil may fail to react to light but retain 
its reaction to convergence and accommodation 
(the Argyll-Robertson phenomenon), a common early 
symptom of tabes dorsalis. 



FIFTH AND SEVENTH CRANIAL NERVES 339 

E. Accommodation varies with age, and with the 
refractive error of individual eyes. Making accepted 
allowances for the degree of presbyopia according to 
age, and correcting refractive errors, accommodation 
is tested with standard test type. Paralysis of accom- 
modation is found in total oculo-motor paralysis, 
in lesions of the accommodation nucleus, and in diph- 
theritic paralysis. 

Trigeminal Nerve. — Fifth cranial (trigeminus) 
nerve is to be tested for its motor part by observing 
the action of the chewing muscles. Their paralysis 
may occur as a result of cerebral lesions lying in the 
vicinity of the trigeminus nucleus, or affecting the 
efferent trigeminus fibres. The sensory distribution 
may be tested in the usual way, as far as the skin 
area is concerned. The sense of taste is to be tested 
with the tongue protruded, for if it were drawn in, 
to test the sensations produced by acid or salt, the 
glosso-pharyngeal nerve terminals at the base of the 
tongue would come into play and defeat the test. 
Corneal sensibility is tested, and the corneal reflex 
elicited, by touching the cornea with a small object, 
such as a pin head. 

Seventh Cranial (Facial) Nerve. — Evidences of 
facial palsy are to be found in obliteration of wrinkles 
on the side affected, diminution or loss of voluntary 
movement, and of the reflexes. The cheek is relaxed, 
and flaps in breathing, the eye is open, the mouth drawn 
to the healthy side. The palate may hang lower on the 
affected side, the normal tear secretion may be affected, 
as the tear sac muscle is paralyzed, with resulting droop- 



340 EXAMINATION OF THE NERVOUS SYSTEM 

ing of the lower lid, and overflow of tears. The nasal 
opening on the affected side seems smaller, owing to 
paralysis of the levator alse nasi. Saliva may escape 
on the paralyzed side owing to paralysis of lip muscles, 
and whistling becomes impossible. There may be a 
drooping of the ear on the affected side. 

According to the position of the lesion, i. e., supra- 
or infranuclear, the signs of paralysis are found to be 
different. A central paralysis (supra-nuclear) does 
not give paralysis of the upper facial muscles, nor 
interference with taste and secretory functions, 
although there is a less vigorous closure of the eye on 
the affected side. Neither atrophy of, nor electrical 
changes in, the facial muscles occurs in central facial 
paralysis. 

In nuclear or infranuclear paralysis there is an 
increased acuteness of hearing especially for low notes 
on the affected side, owing to paralysis of the 
stapedius muscle. There is also some disturbance of 
taste, and diminished flow of saliva on the affected side, 
when the fibres of the chorda tympani nerve are injured. 

Eighth Cranial (Auditory) Nerve. — The diffi- 
culty of eliminating disease of the ear itself, even by 
expert otoscopic examination, and the many doubtful 
conclusions as a result of even carefully made tests 
of air and bone conduction, make it apparent that 
diagnosis of auditory paralysis is an unreliable one. 
However, if the ear appears to be normal and both air 
and bone conduction of sounds, easily appreciated on 
one side, are not heard upon the other side, we may 
conclude that there is paralysis of the auditory nerve. 



NINTH, TENTH, ELEVENTH CRANIAL NERVES 341 

When simulation of deafness in one or both ears is 
suspected, various devices can be used to betray the 
patient into inconsistencies, and proove the simulation. 
Ninth, Tenth, and Eleventh Cranial (Glosso- 
pharyngeal, Vagus, Spinal Accessory) Nerves. — 
Since these nerves receive fibres from both hemispheres 
as do the nerves supplying the eye muscles, unilateral 
hemispheric lesions cause little or no interference with 
their functions. The trapezius, except its clavicular 
portion, alone of all the muscles controlled by this 
group may show paralysis, because its fibres are for 
the most part entirely crossed and are thus often 
affected in a hemiplegia. Involvement of these 
three nerves in their course or in the medulla, i. e., 
within the cranium, is evidenced by lack of palate 
control, interference with swallowing, imperfection 
in phonation, deficient closure of the glottis, choking, 
from inability to prevent access of foreign particles, 
swallowed or inhaled, to the larynx, imperfect cough, 
or entire inability to cough. Unilateral involvement 
of the recurrent laryngeal nerve causes narrowing of 
the glottis, and the affected cord remains in adduction. 
Obstruction, and effective stenosis, at the glottis may 
result from bilateral inferior laryngeal paralysis, and 
loss of sensitiveness of the larynx to foreign particles. 
Bilateral paralysis of the vagi may cause persistent 
tachycardia; unilateral vagus paralysis need not, and 
usually does not, affect the heart rate. Unilateral 
paralysis of the sterno-cleido-mastoid muscle causes a 
moderate twisting of the head to the paralyzed side 
with a slight elevation of the chin. Unilateral paralysis 



342 EXAMINATION OF THE NERVOUS SYSTEM 

of the trapezius gives various defects of position of 
the shoulder and arm according to the parts of the 
muscle that are affected, complete paralysis causing 
a falling of the shoulder, a prominence of the shoulder 
blade outward and upward and a slight impairment 
of power to lift the arm. 

The Twelfth Cranial (Hypoglossus) Nerve. — 
The functions of chewing, swallowing, and speaking 
are noticeably interfered with in marked hypoglossal 
paralysis, although, in unilateral paralysis, it may be 
difficult to detect the errors, especially if a little time has 
elapsed and facility has been reacquired by practice. 

Pathologic Gaits and Postures. — Characteristic gaits 
and postures are assumed in certain nervous diseases. 
We distinguish: 

(a) The paraplegic gait : dragging of the legs slowly 
forward; (6) the hemiplegic gait: affected leg is dragged, 
twisted or swung forward by the pelvis; (c) the ataxic 
gait : random and incoordinate swing or stepping of the 
foot out of line, on the heels, or up in the air, coming to 
the ground hard; (d) the spastic gait: stiff or jumping 
movements of legs; feet hug the floor; knees tight 
together or stiff; (e) the gait in sciatica: the leg is 
fixed to the pelvis usually, the vertebral column is 
usually curved (convex to the affected side in the 
lower part and concave in the upper part) ; (/) the gait 
of propulsion and retropulsion : in paralysis agitans, 
inability to start or stop quickly; (g) the staggering 
gait: as seen in disturbances of equilibrium from the 
effects of alcohol, cerebellar tumor, diseases of the 
inner or middle ear, and lead encephalopathy. 



CHAPTER XI 

ACCESSORY METHODS AND ORDER OF 
PHYSICAL EXAMINATION 

Accessory methods of physical examination — X-rays — Electro- 
cardiograph and electro-phonograph — Polygraph — Tonometer 
— Order of physical examination— Standard classifications of 
pulmonary tuberculosis. 

ACCESSORY METHODS OF PHYSICAL 
EXAMINATION 

With the value of early diagnosis appreciated, 
and with the benefit derived from the use of precise, 
rather than general estimates, and measurements of 
the physical acts resulting from bodily functions, in 
mind, certain instrumental procedures should be here 
mentioned, merely to call attention to the necessity 
of their employment in certain cases, and to insure the 
reader against considering that the unaided senses are 
always sufficient means for arriving at a diagnosis. 

The .T-ray, the electro-cardiograph, electro-phono- 
graph, the polygraph, the tonometer, give us help, 
at times establishing a diagnosis, at others adding to 
its completeness. 

X-Rays. — The differences between the various tissues 
of the body, in their capacity to obstruct or permit the 
passage of Rontgen rays, is made the basis of further 



344 METHODS OF PHYSICAL EXAMINATION 

exact study of the position, and size of the viscera in 
health, and of alterations in size, position, structure, 
or presence of adventitious material in disease. 

The orthodiagraphic method of using the rays obvi- 
ates the error due to dispersion of the rays, and permits 
accurate outlining of organs, at rest or when altered 
in shape and position by movements of their own or 
the parietal musculature, as in outlining the heart 
and great vessels or dilatation of them. 

By the stereoscopic method of studying the results of 
Rontgen ray exposures, an optical illusion is produced, 
which makes objects appear in their relations in three 
planes of space, instead of in only two dimensions. 

In the lungs, assistance may be had in some cases 
where tuberculous processes seem to give no physical 
signs, or but doubtful ones on percussion or ausculta- 
tion. 

Inflammations of the pleura and lungs, when not 
positively identified or exactly localized by physical 
examination, are often clearly shown by the Rontgen 
rays. The position and size of the heart, and great 
vessels, may be determined with more accuracy than 
is possible by percussion and auscultation. 

In the gastro-intestinal tract, invaluable, and other- 
wise unobtainable, information may often be had by 
the use of bismuth mixtures in stomach or colon, 
or both. The resistance of bismuth to Rontgen rays 
makes it possible to get much information as to the 
size, position, patency, location of obstruction if any, 
functional activity, duration of passage of food mass, 
and relations of the various parts of the gastro- 



METHODS OF PHYSICAL EXAMINATION 345 

intestinal tract to each other, to other organs or to 
inflammatory and neoplastic structures within the 
abdomen. Examination is often profitably made 
before and after emptying the colon. 

By study of the movements of the diaphragm with 
the fluoroscopic screen, and by exposures, with the 
breath held at different phases of respiration, positive 
conclusions can be had in otherwise obscure conditions 
above and below its surface. 

Information as to the presence and location of sus- 
pected foreign bodies, of a resistance to Rontgen rays 
different from that of the normal tissues of the abdomen 
and thorax, is usually obtainable with precision. 

Under certain conditions, intracranial tumors may 
occasionally be detected by their density, or their 
determination of distortion of the bony parts of the 
cranial bones, or their association with abnormal 
bony development. We may learn much as to the 
presence of any of the surgical conditions of the bones 
and joints of the body. 

Wherever the condition of the patient allows of it, 
and the equipment, and an expert to use the instrument, 
and to interpret the results are available, the Rontgen 
ray should be employed in any but the most obvious 
disorders of inaccessible parts of the body. 

Electrocardiograph and Electrophonograph. — While the 
diagnosis of valvular defects of the heart, or defects 
in its muscular action, is usually determinable by 
physical examination of the chest, there are many 
phases of the heart's functions, points in its rhythm- 
icity, conductivity, contractility, and origination of its 



346 METHODS OF PHYSICAL EXAMINATION 

impulses which can be suspected, but not proved, 
except with the aid of such instruments as the electro- 
cardiograph, and the electrophonograph. By record- 
ing the incidence, and passage of the currents of action 
in the heart, and by making synchronous records of 
the sound vibrations produced by the heart, and of 
the peripheral physical sequelae of the heart beat, 
much of value to the diagnostician as well as to the 
physiologist and pathologist has been made a matter 
of record and comparison. 

Polygraph. — When the expensive and elaborate para- 
phernalia necessary for electrocardiographic records 
is not available, the simpler machinery for noting 
movements of the heart, and of the blood in the 
arteries, veins, or viscera at a distance from the heart, 
as by the polygraph, often adds to the accuracy of a 
physical diagnosis. 

Tonometer. — In spite of training, and natural delicacy 
of touch, and minute attention on the part of the exami- 
ner, the physical factors of the blood flow are but imper- 
fectly observed by a digital examination of the pulse. 
The simple procedure of measuring the systolic, and 
diastolic pressures in the arteries of the body, as in 
those of the arm or lower leg, if necessary in different 
positions of the body, is so important a maneuver 
that it should form a part of every physical examina- 
tion. There are many methods and instruments 
available for this procedure. 



ORDER OF PHYSICAL EXAMINATION 347 



ORDER OF PHYSICAL EXAMINATION 

For the sake of having a reasonably complete record 
of a physical examination, it is imperative that the 
student should become so used to a logical and definite 
order that omissions are unlikely to occur. To this 
end the following scheme or order of physical examin- 
ation is included: 

General Appearance. — Height, weight, nutrition, 
type of physique, active and passive posture. Expres- 
sion. 

Constitutional Signs. — Body temperature. Pulse 
rate. Respiration rate. 

Psychical Conditions. — Intelligence, consciousness, 
restlessness, convulsions, delirium, apathy, stupor, 
coma, speech, memory. 

Skin. — Texture, color (cyanosis, icterus, pigment), 
moisture, temperature, edema, emphysema, hemor- 
rhages, insect bites, eruptions, scars, collateral, venous, 
or capillary circulation, striae, desquamation. 

Head. — Shape and size, symmetry. 

Eyes. — Position, motion, equality and size of pupils, 
reactions of pupils to light, and accommodation, 
acuteness of vision, conjunctivae. 

Ears. — Hearing, mastoid tenderness, tophi. 

Nose. — Patency of nares, or obstructions, odor, 
secretions. 

Lips. — Color, moisture, eruptions. 

Teeth. — Gums swollen, puffy, pyorrhea, lead line, 
caries, absence, saliva. 



348 ORDER OF PHYSICAL EXAMINATION 

Palate. — Broad, narrow, arched, perforated. 

Neck. — Glands, lymph-nodes, thyroid, enlargement 
or pulsations of veins and arteries, thrills, murmurs, 
venous hum. 

Larynx. — Tracheal tug, cough, voice. 

Pharynx. — Color, exudates, tonsils. 

Esophagus. — Swallowing. 

Vertebrae. — Curvature, tenderness. 

Chest. — Variations in breadth or depth, asymmetry 
of form or function. Abnormal impulses. Shape, 
funnel, rachitic, with rosary, and costal groove. 
Scapulae position. Expansion, measurement. Uni- 
lateral or bilateral bulging or retraction of inter- 
spaces. 

Respiration. — Rate, type, diaphragm phenomenon, 
retraction of interspaces, Biot's or remittent breathing. 
Cheyne-Stokes or periodic breathing, dyspnea, inspira- 
tory or expiratory, cough, expectoration. 

Palpation. — Fremitus, vocal, bronchial, pleuritic. 

Percussion. — Systematic, of whole chest. Particular 
attention to comparison of apices and determination 
of lung borders in inspiration and expiration. 

Auscultation. — Breath and voice sounds, adventitious 
sounds. 

Heart. — Inspection, apex, location and character 
of beat; presence of abnormal pulsation. 

Palpation. — Site and character of apex-beat; site and 
time of thrill or abnormal pulsation. 

Percussion. — Borders of heart, change on altered 
position. 



ORDER OF PHYSICAL EXAMINATION 349 

Auscultation. — Character of first and second sounds, 
or their component parts at the several valvular areas, 
murmurs, place, time, maximum intensity, direction of 
transmission, character, effect of change of position. 

Pulse. — Size, force, frequency, rhythm, tension 
(instrumental determination), vessel wall, character, 
symmetry on two sides, delay. 

Abdomen. — Form, circumference, umbilicus, resist- 
ance, percussion, palpation, visible movements, tumors, 
size, consistency, mobility, relation to respiration and 
to other organs, fluctuation, tenderness, auscultation of 
abnormal sounds. 

Liver. — Upper limit, lower border, character of 
surface and edge, smooth, nodular, tender, pulsating. 

Spleen. — Area of dulness, edge, character of surface. 

Stomach. — Size, visible movements, splashing, ten- 
derness, tumors, if necessary distention with gas or 
fluid and use of tube to empty. 

Kidneys. — Palpation; bladder, retention, palpation, 
and percussion. 

Extremities. — Joints, movements, size, tenderness, 
musculature, atrophy, hypertrophy, altered tonicity, 
trophic abnormalities. Lymph-nodes, inguinal, axil- 
lary, and epitrochlear. 

Reflexes. — Tendon, joint, skin reflexes, also general 
sensibility, locomotion, and muscular efficiency. 

Special examinations to be made whenever necessary 
to a complete diagnosis. Ophthalmoscopic, laryngo- 
scopy, and rhinoscopic, otoscopic, rectal, vaginal, 
urethral, and cystoscopic, special neurological tests, 
sounding of esophagus and stomach. 



350 STANDARD CLASSIFICATIONS 

STANDARD CLASSIFICATIONS OF PULMONARY 
TUBERCULOSIS. 

For the sake of accuracy in using terms descriptive 
of the various stages or degrees of severity of pulmo- 
nary tuberculous lesions, the student is advised to 
avail himself of the definitions which follow. 

A. Turban's Classification. 

According to Turban we may define the lesion as of 
three grades: 

By grade I, we mean a slight lesion extending at most 
to the volume of one lobe or two half lobes. 

By grade II, slight lesion extending farther than I, 
but at most to the volume of two lobes; or a severe 
lesion extending at most to the volume of one lobe. 

By grade III, all lesions which in extent of the parts 
affected exceed II. 

By " slight lesion" we understand disseminated cen- 
tres of disease which manifest themselves physically by 
slight dulness, by harsh, feeble, or broncho-vesicular 
breathing, and by rales. 

By " severe lesion" we mean cases of consolidation 
and excavation such as betray themselves by marked 
dulness, by tympanitic resonance, by very feeble 
broncho-vesicular, bronchial or amphoric breathing, 
by rales of various kinds. 

Purely pleuritic dulness, unless marked, is to be left 
out of account; if it is serious the pleurisy must be 
mentioned under the head of tuberculous complications. 



STANDARD CLASSIFICATIONS 351 

B. The National Association Classification. 

The National Association for the Study and Pre- 
vention of Tuberculosis has adopted the following 
classification : 

Incipient (Favorable). — Slight initial lesion in the 
form of infiltration limited to the apex or a small part 
of one lobe. No tuberculous complications. Slight or 
no constitutional symptoms (particularly including 
gastric or intestinal disturbances or rapid loss of 
weight). Slight or no elevation of temperature, or 
acceleration of pulse at any time during the twenty- 
four hours, especially after rest. Expectoration usually 
small in amount or absent. Tubercle bacilli may be 
present or absent. 

Moderately Advanced. — No marked impairment 
of function either local or constitutional. Localized 
consolidation, moderate in extent with little or no evi- 
dence of destruction of tissue; or disseminated fibroid 
deposits. No serious complications. 

Far Advanced. — Marked impairment of function, 
local and constitutional. Localized consolidation 
intense: or disseminated areas of softening; or serious 
complications. 

Miliary Tuberculosis (vide page 210). 



INDEX 



Abdomen, auscultation of, 314 
inspection of, 311 
palpation of, 312 
percussion of, 313 
wall of, 319 
Abscess of lung, 28, 30, 203 
Accessory methods of examina- 
tion, 343 
electrocardio- 
graph, 345 
electrophono- 

graph, 345 
polygraph, 346 
tonometer, 346 
z-ray, 343 

orthodiagraph^ 
method, 204, 
344 
stereoscopic, 
344 
Adventitious respiratory sounds 
or rales, 133 
cavernous, 146 
classification of, 

133 
crepitant, 28, 143, 

187 
dry bronchial, 140, 

173, 178 
gurgling, 146 
indete r in i n a t e, 

151 
laryngeal and tra- 
cheal, 134 
metallic tinkling, 
149, 165 
23 



Adventitious respiratory sounds, 
moist bronchial, 
134, 173, 175 
pleural or friction, 
26,147,187,298 
sibilant and sono- 
rous, 141, 178 
splashing or suc- 
cussion, 147, 
150, 196, 300 
subcrepitant, 137, 
138, 139 
Air in pleural space, 25 
Amphoric resonance, 82 

conditions causing, 83 
respiration, 127 
voice, 162 
whisper, 162 
Analysis of sounds, 33 
Aneurism, thoracic, 30, 32, 281, 

304 
Aorta and pulmonary artery, 
relations of, to chest-walls, 
227 
Aortic direct murmur, 270, 291 
diastolic non-regurgitant 

murmur, 272, 291 
lesions, diagnosis of, 291 
regurgitant murmur, 272, 
291 
Apex beat of heart, modifica- 
tion of, 224, 225, 238, 282, 
286, 295 
Apoplexy, pulmonary, 75, 203 
Argyll-Robertson pupil, 338 
Artery, pulmonic, and aorta, 
relation of, to walls of chest, 
227 



354 



INDEX 



Asthma, 29, 142, 177 
Atrophy, senile, of lungs, 180, 

183 
Auscultation, definition of,, 18, 
86 

in disease, 109 

in health, 87, 93 

mediate and immediate, 88 

position for, 90 

rules in practice of, 89 



B 

Babinski phenomenon, 333 
Blood currents, aortic, 258, 
259 
direct, 258, 261 
mitral, 259 
pulmonic, 261 
regurgitant, 259 
relation of, to heart 

sounds, 259 
tricuspid, 261 
Brain, disease of, general mani- 
festations of, 321 
signs of, general, 321 
local, 322, 325 
Bread, use of, to imitate pul- 
monary signs, 55, 80, 81 
Bronchi, obstruction of, 29, 32 
relations of, to chest-wall, 
47, 48, 50 
Bronchial rales, dry, 141, 173 
moist, 135, 173, 175 
respiration, 117 
causes, 118 
whisper, increased, 159 
normal, 105 
Bronchitis seated in large bron- 
chial tubes, 28, 172 
in small bronchial 
tubes (capillary), 
28, 174 
Broncho-cavernous respiration, 

125 
Bronchophony, 153 

whispering, 155, 159 
Bronchorrhagia, 28 
Bronchorrhea, 28, 137 



Broncho-vesicular 

119 
Bruit de diable, 271 



respiration, 



Capillary bronchitis, 174 

pulse, 255 
Cardiac space, superficial and 

deep, 59, 183, 223, 226 
Cavernous rale, 146 
respiration, 122 

imitation of, 125 
Cavities, pulmonary, 30, 32, 

211, 219 
Charcot joint, 334 
Chest, anatomy and physiology 
of, 21, 222 
regional divisions of, 41, 
57, 95, 
Cirrhosis of lung, 219 
Clicking rale, 141 
Cogged- wheel respiration, 131 
Collapse of lung, 27, 175 
Conditions, morbid physical, 
incident to different 
diseases of the respi- 
ratory system, 25, 
168 
summary of, 31 
physical, of heart in dis- 
ease, 222, 236 
in health, 222 
represented by amphoric 
resonance, 82 
by cracked-metal reso- 
nance, 84 
by dulness, 76 
by flatness on percus- 
sion, 74 
by tympanitic reso- 
nance, 78 
by vesiculotympanitic 
resonance, 81 
Congestion, hypostatic, of lungs, 

edema in, 208 
Coughing, signs obtained by, 

166 
Cracked-metal resonance, 84 



INDEX 



355 



Cracked-metal resonance, imi- 
tation of, 84 

Cranial nerves, tests of, 335- 
342 

Crepitant rale, 28, 143, 187 



Death rattles, 134 
Diaphragmatic hernia, 220 
Diseases of respiratory system, 
physical conditions incident 
to, 25, 168 
Dulness, 76 

conditions causing, 76 
hepatic, 61, 64 
tympanitic, 78, 218 
Duration of sounds, 38 
Dysphagia in thoracic aneu- 
rism, 305 



Echo, amphoric, 162 

Edema, pulmonary, 28, 32, 77, 

145, 176, 206 
Egophony, 155, 189 
Electrocardiograph, 345 
Electrophonograph, 345 
Emphysema, diagnosis of, 182 
interlobular, 28 
pulmonary or vesicular, 27, 
32, 81, 131, 179, 180, 
183, 184 
rhythm of respirations in, 
182 
Empyema, 26, 185, 192 

pulsating, 192 
Endocardial murmurs, 258, 

279 
Endocarditis, diagnosis of, 297 
Exocardial murmur, 258, 279 
Exophthalmic goitre, 302 
Expiratory sound, prolonged, 

129 
Exploration, physical, different 

methods of, 17 
Exudation in air-vesicles, 28 ; 32 



Fissures, interlobar, 23, 48, 49 
Flatness, 74 

conditions causing, 74 
hepatic, 61, 64 
Flint murmur, 264 
Fremitus, in different regions 
1U2 
increased, 156, 158 
diminished, 164 
normal, vocal, 100 
suppressed, 164 
Friction murmur, pericardial, 
258, 298 
pleuritic, 26, 147, 186, 
298 



G 

Gaits, pathologic, 342 
Gangrene, pulmonary, 27, 30, 

205 
Gerhardt's tone change, 84 
Glottis, edema of, 170 

paralysis of, 169, 308 

spasm of, 169 • 
Goitre, exophthalmic, 301 
Grafe's sign, 337 
Graham-Steell murmur, 277 
Gurgling rale, 146 



Head's zones, 328 
Heart, abnormal impulses of, 
238 
anatomical relations of, 223 
angina pectoris, 301 
apex beat of, 25, 224, 225 , 

238, 283, 284, 286 
arrhythmias of, 253 
auricular fibrillation in, 297 
congenital defects of, 304 
patent ductus 
arteriosus, 305 
foramen ovale. 
305 



356 



INDEX 



Heart, congenital defects of, 
patent inter- 
vent r icular 
septum, 305 
pulmonary valve, 

294 
transposition of 

viscera, 304 
tricuspid valve, 

293 
valvular, 305 
diagnosis of diseases of, 281 
dilatation of, 237 
enlargement of, 236, 287 
extrasystoles of, 252 
first sound of, intensified, 
243 
weakened, 244 
Flint murmur, 264 
functional disorders of, 301 
angina pectoris, 

301 
exophthalmic 

goitre, 302 
palpitation, 302 
murmurs, mitral, 257 
hypertrophy of, 238 

and dilatation of, 281 
signs of, 282, 286, 
287 
inflammation of, 295 
murmurs of, 222, 228, 256, 

299 
muscle, diseases of, 295 

acute mvo carditis 

295 
in anemia, 295 
auricular fibrilla- 
tion, 297 
chronic myocar- 
ditis, 296 
heart-block, 297 
in infectious dis- 
eases, 295 
perpetual irregu- 
larity, 252 
normal, 282 
palpitation of, 302 
physical condition of, in 
disease, 222, 236 



Heart, physical condition of, 
in health, 222,223 
sounds of, 222, 228 

abnormal modifica- 
tions of, 243 
five in number, 234 
mechanism of, 231, 

232 
mitral systolic, 233, 

234, 247 
pulmonic, change of, 
causes of, 
246 
intensity of, 
at differ- 
ent ages, 
233 
reduplication of, 248 
second, aortic, weak- 
ened, 245 
pulmonic, weak- 
ened, 246 
third, 229 

tricuspid systolic, 233, 
234, 247 
valvular lesions of, 240, 288 
aortic, 291 
mitral, 288 
pulmonic, 294 
tricuspid, 293 
Hemorrhagic infarcts, 27, 75, 

203 
Hernia, diaphragmatic, 31, 32, 

220 
Hum, venous, 271 
Hydatids of lung, 27 
Hydrothorax, 26, 184, 192 



Indeterminate rales, 151 
Infarctus, hemorrhagic, 27, 75, 

203 
Inspiratory sound shortened, 128 
Intensity of normal and abnor- 
mal sounds, differences of, 
34, 35, 53, 78 
Interrupted respiration, 131 
Interstitial pneumonia, 219 



INDEX 



357 



Jerking respiration, 131 



Kidneys, palpation of, 318 



Laryngeal and tracheal rales, 
134 
respiration, 91 
voice, 99 
Laryngismus stridulus, 169 
Larynx, foreign bodies in, 171 
and trachea, affections of, 
32, 170, 171 
tumors of, 171 
ulcers of, 171 
Lesions valvular, of heart, 240, 
288 
diagnosis of, 288 
Liquid in chest, 26, 28, 31, 74 
Liver, dulness over, 61, 64 
flatness over, 61, 64 
information obtained from 
examination of, 315 
Lobular pneumonia, 27, 174, 176 
Lobules, pulmonary, collapse 

of, 27, 174 
Lung, solidification of, 27, 32, 
40, 118, 155, 156 

M 

Metallic tinkling, 149, 151, 

165, 196 
Mitral lesions, diagnosis of, 288 
murmurs, diastolic, 265 
direct, 262 
presystolic, 262 
regurgitant, 266 
systolic non-regurgi- 
tant or intraventri- 
cular (Flint mur- 
mur), 267 
Murmur, aortic direct, 270, 273, 
274, 278 
prediastolic 272 



Murmur, cardiac, 222, 228, 241, 
256, 262, 280, 296, 297 
diastolic or non-regurgitant 

272 
endocardial, 258, 279 

coexisting, 273 
exocardial, 258, 279 
mitral causation of, 268, 
289 
diastolic, 265, 290 
direct, 262 
limits of, 264 
mechanism of, 262 
presystolic, 262, 290 
regurgitant, 267, 290 
systolic, non-regurgi- 
tant, or intraven- 
tricular, 267, 288 
thrill with, 265 
without mitral lesions, 
263, 265, 290 
normal vesicular, 93 

in different regions, 95 
pericardial or friction, 258, 

279 
pulmonic direct, 276 

regurgitant (Graham- 
Steell), 275 
regurgitant, 271 
tricuspid direct, 275 
regurgitant, 277 
vesicular causes, 113 
diminished, 112 
increased, 111 
suppressed, 115 
Murmurs, endocardial, 258, 261 
exocardial, 258, 279 
facts of importance relat- 
ing to, 278 
groups of, 258 . 
hemic, 257 

organic and inorganic, 257 
Myocarditis, 295 



N 

National association classifica- 
tion of pulmonary tubercu- 
losis, 351 



358 



INDEX 



Neoplasm of lung, 27, 30, 208 
Nervous system. See also 
Brain, 325 
cranial nerves, exami- 
nation of, 335-342 
electrical irritability 
of, 334 
in tetany, 
335 
examination of, 321 
general, 325 
special, 335 
motility tests of, 325 
abnormali- 
ties of, 326, 
327 
pathologic gaits and 

postures, 342 
reflexes of, cutaneous, 
329 
tendon, 329 
sensibility tests of, 328 
Head's zones, 
328 



Order of physical examina- 
tion, 347 

Organs, respiratory, anatomy 
and physiology of, 20 



Palpitation, cardiac, 302 
Pectoriloquy, 160 
Percussion, analysis of sounds 
in, 53 

definition of, 18 

in disease, 73 

in health, 51 

instruments for, 52 

modes of performing, 52, 
68 

objects of, 53 

position for, 69, 70 

respiratory, 66 

rules in practice of, 69 



Percussion, sense of resistance 
in, 85 
signs of disease furnished 

b y> 73 

Pericardial or friction murmur, 
258, 279, 300 
sac, liquid within, 241 
surfaces, roughness of, 241 
Pericarditis, chronic, 299 

diagnosis of, 298 
Phonendoscope, 88 
Phthisis, 27, 28, 32, 123, 211 
advanced, 213, 219, 350 
differential diagnosis of, 

217 
fibroid, 219 

groups of cases in, 212, 350 
incipient, 212, 215, 216, 

350 
moderate, 212, 350 
signs, direct and accessory 
of, 214 
Physical examination, order of, 

347 
Pitch of normal and abnormal 

sounds, 34, 35, 54 
Pleural rales, 26, 147, 186, 299 
Pleurisy, acute and chronic, 26, 
31, 40, 184 
chronic, signs of, 190 
diaphragmatic, 186 
exceptional signs of, 193 
first stage of, friction sound 
in, 186 
signs of, 186 
mediastinal, 186 
paravertebral angle of dul- 

ness in, 188 
second stage of, horizontal 
and S-shaped 
lines in, 187 
signs of, 187 
Pleuropneumonia, 197 
Pneumohydropericardium, 300 
Pneumohydrothorax, o26, 32, 
194 
amphoric voice in, 196 
metallic tinkle in, 196 
Pneumonia, acute lobar, 26, 197 
circumscribed, 203 



INDEX 



359 



Pneumonia, crepitant rale in, 202 
embolic, 27, 204 
interstitial, 27, 219 
lobular, 27, 174, 176 
signs of abscess in, 203 
in first stage, 198 
of purulent infiltra- 
tion in, 203 
in second stage, 199 
in third stage, 202 
Pneumopyo thorax, 194 
Pneumorrhagia, 28, 205 
Pneumothorax, 26, 32, 124, 194 

coin test for, 197 
Polygraph, 346 
Postures, pathologic, 342 
Precordia, 223, 236 
Pulmonary apoplexy, 203 

edema, 28, 32, 75, 145, 176, 

206 
gangrene, 27, 30, 205 
Pulmonic direct murmur, 276 
lesions, diagnosis of, 294 
regurgitant murmur, 277, 
294 
Pulse, arterial, 249 
capillary, 255 
character of vessel wall, 

255 
frequency of, 250 
rapidity of, 254 
regularity of, 251 
size of, 253 
tension of, 254 
venous, 255 
Pupils, inequality of, in thoracic 

aneurism, 308 
Pyothorax, 26 



Quality of normal and abnor- 
mal sounds, 35-37, 53 
terms denoting, 38 



R 

Rale, cavernous or gurgling, 
146 



Rale, crepitant or vesicular, 28, 
143 
indeterminate, 151 
metallic tinkling, 149, 165 
splashing or succussion, 
147, 150, 196, 300 
Rales, 133 

classification of, 133 

dry bronchial, 141, 173, 

178 
fine bubbling or subcrepi- 

tant, 134, 135, 137 
laryngeal and tracheal, 133 
moist bronchial, 135, 175, 

178 
pitch of, 29 
pleural or friction, 26, 147, 

186, 299 
tracheal, 29, 133 
sibilant and sonorous, 141, 
178 
Regions, anatomical relations 
of, 46 
division of chest into, 41 
sections of chest corre- 
sponding to, 46, 58, 96 
Resistance, sense of, in percus- 
sion, 85 
Resonance, absence of, or flat- 
ness, 74 
amphoric, 82 
cracked metal, 84 
in different regions, 57 
diminished, or dulness, 76 
disparity of, on the two 

sides, 65 
normal, vesicular, on per- 
cussion, 55 
vocal, over larynx and 
trachea, 99 
over chest, 100 
standard for, 65 
tympanitic, 57, 58, 78 
variations in different re- 
gions of chest, 57 
vesiculo-tympanitic, 81, 

180 
vocal, diminished, 162 
increased, 156 

causes of, 156 



360 



INDEX 



Respiration, abnormal modifi- 
cations of, 110 
amphoric, 127 

imitation of, 128 
bronchial or tubular, 117, 

308 
broncho-cavernous, 125 

-vesicular, 119 
cavernous, 122 
in different regions, 95 
diminished, 112, 170, 175, 

181 
harsh, 119 
indeterminate, 119 
interrupted, 131 
normal, laryngeal, and tra- 
cheal, 91 
vesicular murmur of, 
93 
puerile, 112 
rude, 119 

supplementary, 112 
suppressed, 115 
vesicular murmur of, in- 
creased, 111 
vesiculocavernous, 126 
Respiratory organs, anatomy, 
physiology of, 21 
physical conditions in- 
cident to diseases 
of, 25, 31, 168 
Rhythm, respiratory, in ''em- 
physema, 182 
Romberg's symptom, 327 



S 

Signs, 18 

healthy and morbid, dis- 
tinctive characters of, 
18, 33 
object of, 19 

obtained by coughing, 166 
by percussion in disease, 73 

in health, 51 
physical, definition of, 18, 
respiratory, classification 
of, 110 
in disease, 109, 110 
et seq. 



Signs, respiratory, in health, 86 
significance of, 39 

as representing phy- 
sical conditions, 40 
vocal, in health, 99 
of disease, 152 
Sounds, differences of intensity 
in, 34, 35 
in pitch, 35 
in quality, 36 
normal and abnormal, 18, 

110 < 
rhythm of, 38 
Splashing or succussion sounds, 

147, 150, 196, 300 
Spleen, 62, 317 
Stethoscope, advantages of, 88 

binaural, 88 
Stomach, 62, 314 



Thoracic aneurism, 306 

diagnosis of, from em- 
pyema, 310 
Thrill, with mitral presystolic 
murmurs, 265 
with thoracic aneurism, 
307 
Thymus gland, 63 
Tinkling, metallic, 147, 165, 

196 
Tonometer, 346 
Trachea, affections of, 32, 169 
Tracheal respiration, 91 
Traube's space, 63 
Tricuspid, direct murmur, 275, 
293 
lesions, diagnosis of, 293 
regurgitant murmur, 275, 

294 
safety-valve function of, 
262 
Tuberculosis, acute, 176, 210 
classification of, 350 
miliary, 192 
Tubular respiration, 117 
Tumor within chest, 31, 32, 75, 
208, 300 



INDEX 



Turban's classification of pul- ! Vocal 

monary tuberculosis, 350 
Tussive signs, 166 

significance of, 167 
Tympanitic dulness, 78, 218 
resonance, 67, 78 

conditions causing, 



Valvular cardiac lesions, 240, 
288 
aortic, 291 
mitral, 288 
pulmonic, 294 
tricuspid, 293 
Venous hum, 271 

pulse, 255 
Vesicular rale, 143 

resonance, normal, .53, 54 
Vesiculocavernous respiration, 
126 
-tympanitic resonance, 81, 
180 
conditions caus- 



esonance, normal, 99, 
100 
in different re- 
gions, 103 
increased, 156-158 
signs of disease, 152 
Voice, abnormal, 152 
amphoric, 162 
larvngeal and tracheal, 99 
normal, 100, 102 



W 



ing, 81 
\ ocal fremitus, diminished or 
suppressed, 164 
increased, 156-158 
normal, 100, 103 
resonance, diminished and 
suppressed, 162 



Wavy respiration, 131, 214 
Whisper, amphoric, 162 

bronchial, increased, 159 
cavernous, 160 
in different regions, 107 
laryngeal or tracheal, 106 
normal bronchial, 1G5 
Whispering pectoriloquy, 161 
Williams' tracheal tone, 84 
Wintrich's tone change, 84 



X-ray, accessory to physical 
examination, 315, 343 
diaphragmatic hernia, 221 
foreign bodies in chest, 171 



24 



SEP 3D 1912 



ill 

I 



1 1 H ■ ^^^^^^H^^B 




Sslffil 






%VXV D f>P l ffp Pf WOPT> 



LIBRARY OF CONGRESS # 



029 827 891 1 




